RESEARCH Open Access

Mental Health First Aid guidelines for helping asuicidal person a Delphi consensus study in IndiaErminia Colucci1 Claire M Kelly2 Harry Minas1 Anthony F Jorm2 Sudipto Chatterjee3

Abstract

Background This study aimed to develop guidelines for how a member of the Indian public should providemental health first aid to a person who is suicidal

Methods The guidelines were produced by developing a questionnaire containing possible first aid actions andasking an expert panel of Indian mental health clinicians to rate whether each action should be included in theguidelines The content of the questionnaire was based on a systematic search of the relevant evidence and claimsmade by authors of consumer and carer guides and websites Experts were recruited by SC EC and HM The panelmembers were asked to complete the questionnaire by web survey Three rounds of the rating were carried andat the end of each round items that reached the consensus criterion were selected for inclusion in the guidelinesDuring the first round panel members were also asked to suggest any additional actions that were not covered inthe original questionnaire (to include items that are relevant to local cultural circumstances values and socialnorms) Responses to the open-ended questions were used to generate new items

Results The output from the Delphi process was a set of agreed upon action statements The Delphi processstarted with 138 statements 30 new items were written based on suggestions from panel members and of these168 items 71 met the consensus criterion These statements were used to develop the guidelines appended tothis paper Translated versions of the guidelines will be produced and used for training

Conclusions There are a number of actions that are considered to be useful for members of the public whenthey encounter someone who is experiencing suicidal thoughts or engaging in suicidal behaviour Although theguidelines are designed for members of the public they may also be helpful to non-mental health professionalsworking in health and welfare settings

BackgroundAs reported by WHO [1] suicide is a huge but largelypreventable public health problem causing almost halfof all violent deaths and resulting in one million fatal-ities every year (ie almost 3000 every day) as well aseconomic costs in the billions of dollars Estimates sug-gest fatalities could rise to 15 million by 2020 Forevery person who completes suicide 20 or more make asuicide attempt resulting in injury hospitalization andemotional and mental trauma although no reliable dataare available on its full extent [12] Worldwide suiciderates have increased by 60 over the last 50 years Theincrease has been especially marked in developing

countries [1] The worldwide increase has been particu-larly alarming amongst young people aged 15 to 25years [2]For every suicide death there are scores of family and

friends whose lives are devastated emotionally sociallyand economically [2] For these family members andfriends affected by suicide or attempted suicide theemotional impact may last for many years [1]A member of the community who is close to the sui-

cidal person such as a friend family member co-workeror classmate is likely to be the first person to noticehints that could be ldquoreadrdquo as suicide warning signs bytrained or experienced eyes However few have theknowledge and skills required to recognize the immi-nent risk of suicide and to assist in preventing suicideFor this reason we decided to produce general guide-lines for how a member of the public should provide

Correspondence ecolucciunimelbeduau1Centre for International Mental Health Melbourne School of PopulationHealth The University of Melbourne Parkville Victoria 3010 Australia

Colucci et al International Journal of Mental Health Systems 2010 44httpwwwijmhscomcontent414

copy 2010 Colucci et al licensee BioMed Central Ltd This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (httpcreativecommonsorglicensesby20) which permits unrestricted use distribution and reproduction inany medium provided the original work is properly cited

first aid to a person who is suicidal ie has expressedsuicidal thoughts or intent whether overt or covert orhas taken action toward making a suicide attempt Sim-ple and practical guidelines might help such a person toencourage a suicidal individual to seek professional helpor decide against suicide These guidelines can beapplied in training courses for the publicFirst aid training is widespread throughout the world

giving members of the public skills to help an injuredperson before medical help arrives There are manyorganizations offering first aid training but the firstaid practices taught in these courses generally conformto national guidelines While first aid training is com-mon it generally ignores mental health crises such ashow to assist a suicidal person Nevertheless therehave been efforts to develop training for the publicthat does cover these issues such as Applied SuicideIntervention Skills Training (ASIST) [3] and MentalHealth First Aid (MHFA) training [4] Unfortunatelythere is limited evidence to guide the content of suchtraining While randomized controlled trials providethe highest standard of evidence it is not feasible orethical to carry out such trials to evaluate specific sui-cide first aid strategies In the absence of high qualityevidence the best option for developing guidelines isexpert consensus There are formal methods for asses-sing expert consensus that have been used in severalareas of health research One of the most commonlyused consensus method is the Delphi process (see [5])There are many variants but all involve a group ofexperts making private ratings of agreement with a ser-ies of statements feedback to the group of a statisticalsummary of the ratings and then another round ofrating Delphi group members do not meet so it ispossible to do studies using mail or the Internet Theoutput from the process is statements for which thereis substantial consensus in ratings The Delphi methodhas been used in health research since the mid-70 s[6] We have used the Delphi method to develop sui-cide first aid guidelines for developed English-speakingcountries [7] as well as mental health first aid guide-lines for non-suicidal self injury [8] panic attacks [9]psychosis [10] depression [11] and eating disorders[12] However we do not believe these guidelines willnecessarily apply in countries with very different cul-tures and healthcare systems We therefore wished toexplore the possibility of developing suicide first aidguidelines for a number of Asian countries This pro-ject was undertaken to establish whether the use of theDelphi method is a feasible approach in the develop-ment of suicide first aid consensus guidelines for Asiancountries This method was previously successfullyimplemented in the production of first aid guidelinesfor psychosis in Asia [10]

The aim of this project was to produce guidelines foruse in particular Asian countries on how a member ofthe public should provide first aid to a person who issuicidal ie has expressed suicidal thoughts or intent orhas made a suicide attempt The project did not aim totest hypotheses rather to develop guidelines on first aidactions based on the consensus of expert clinicians Theproject involved undertaking separate studies in threecountries Japan Philippines and India These threecountries were chosen because they are Asian countrieswith very different cultural and religious contexts differ-ent rates of suicide different levels of economic devel-opment and different levels of availability of mentalhealth services We expected that there would be par-tially different views expressed by the expert panelsabout appropriate guidelines for mental health first aidin relation to suicide [13-16] The present paper pre-sents the results of the study in India Those in Japanand Philippines will be described in subsequent papersTo the best of the authorsrsquo knowledge no study of

this kind has been conducted in these countries before

MethodsThe first aid guidelines were produced using (a) a sys-tematic search of the relevant evidence and claims madeby authors of consumer and carer guides and websites(b) development of a questionnaire on possible first aidactions which was based on the search (c) and the con-sensus of panels of clinicians from each of the countrieson which first aid actions should be included in theguidelines

Systematic search for possible suicide first aid actions inthe literatureAs part of the project to develop suicide first aid guide-lines for developed English-speaking countries a sys-tematic search for possible first aid actions was carriedout This search has involved formal professional litera-ture listed in PubMed and PsycLit and other sourcessuch as existing general mental health first aid manuals[4] other relevant manuals and guides on suicide pre-vention (eg Suicide Prevention Skills Training [17]Mental Health for Emergency Departments [18]) andrelevant web sites (eg Samaritans) This method hasbeen previously published for suicide first aid guidelinesin developed English-speaking countries [7]

Construction of the questionnaireA questionnaire was constructed from a content analysisof the actions indicated in the literature Only state-ments that suggested a potential first aid action(ie what the first aider should do) or relevant awarenessstatements (what the first aider should know) wereincluded in the questionnaire These statements were

Colucci et al International Journal of Mental Health Systems 2010 44httpwwwijmhscomcontent414

Page 2 of 8

grouped based on their common themes and used by aworking group to generate questionnaire items specify-ing what actions a first aider should take No judgmentswere made by the working group about the potentialusefulness of the statements Anything was includedthat fitted the definition of first aid even if contradic-tory to other statementsThe questionnaire developed for English-speaking

countries had 114 items each describing a potentialaction that a first aider could do which could be put tothe panel for rating These items covered the followingbroad areas identification of suicide risk assessing ser-iousness of suicide risk initial assistance talking with asuicidal person no-suicide contracts ensuring safetyconfidentiality and passing time during the crisis Theitems are shown in Additional File 1 For the Asianguidelines we added a few other items based upon theChief Investigatorrsquos previous work on suicide preventionin Asian countries (eg [1419]) Thus the initial ques-tionnaire contained 140 first aid action items plus 13questions on participantsrsquo socio-demographics experi-encetraining and opinions on suicide first aid Open-ended questions to generate additional culturally specificitems were also included Given that this was anexploratory project we used English-language question-naires because the cost of doing it in the expertsrsquo nativelanguages would have been prohibitive

Forming panelsA panel of Indian clinical experts currently working inIndia was formed The experts were recruited by SCHM and EC (see Figure 1) When invitation letterstogether with the Plain Language Statement were sent toprofessionals asking them to be involved they were alsoinvited to nominate any colleagues who they felt wouldbe appropriate panel members During the recruitmentprocess potential participants were informed that one ofthe selection criteria was to be fluent in written EnglishThe number of panel members in previous Delphi stu-dies has varied considerably from 15 to 60 [20] Weaimed to have a minimum of 25 members in a panel

Delphi processIn Round 1 of the Delphi process panel members wereasked to complete an on-line questionnaire This wasadministered using the SurveyMonkey application [21]with the option to complete it by email or paper mail ifthis was not possible (although no participant opted forthis alternative) The questionnaire consisted of a list offirst aid actions to rate Only actions that are do-able bymental health first aiders were included in the list of itemsto be rated Members of the expert panel were given thefollowing instructions to guide their judgments

ldquoThe following questionnaire asks about the bestway a member of the public can help someone whois thinking about or planning to suicide Mentalhealth first aid is defined as help given to someonewho is experiencing a mental health problem or isin a mental health-related crisis until professionalhelp is received or the crisis resolves It does notinclude counselling or therapy In the case of suicidemental health first aid is given until the person deci-des to accept professional help or decides againstsuicide People who offer mental health first aid maybe friends family members colleagues or acquain-tances They may or may not be involved in the per-sonrsquos life before or after offering first aid Forbrevity we will refer to the person offering assis-tance as ldquothe first aiderrdquo When completing thisquestionnaire you will read statements describingpossible actions that the first aider can take to assista suicidal individual You will be asked to rate howimportant each item is as a guideline for a firstaider Please rate as ldquoessentialrdquo or ldquoimportantrdquo thoseitems which you feel should guide most peoplemost of the time when assisting a suicidal personThe statements in this questionnaire were derivedfrom a search of both professional and lay literaturein English-speaking western countries Thereforethere will be actions which would be appropriate formembers of the public in your country which arenot included and there will be actions that may beappropriate in Western countries but not in yourcultural context At the bottom of each page thereis room for you to add suggestions Please considerthe cultural social and religious environment whereyou live and try to add some relevant suggestionson each page The more panel members add to thisquestionnaire the more relevant and useful theguidelines will be for each individual country Thankyou for taking the time to assist us in this importantsuicide prevention projectrdquo

The definition of mental health first aid given to thepanel was ldquoMental Health First Aid is the help providedto a person developing a mental health problem or in amental health crisis The first aid is given until appro-priate professional treatment is received or until the cri-sis resolvesrdquo This definition distinguishes a first aiderrsquosrole from that of a clinician In the case of a suicidalperson the first aider responds by getting professionalhelp for the person and supporting the person andensuring their safety until the crisis has passed Theguidelines needed to focus on the immediate preventionof suicide and not on solving the problems that lead tothe crisis

Colucci et al International Journal of Mental Health Systems 2010 44httpwwwijmhscomcontent414

Page 3 of 8

Figure 1 Stages in the guidelines development

Colucci et al International Journal of Mental Health Systems 2010 44httpwwwijmhscomcontent414

Page 4 of 8

Panelist members were asked to rate each statementaccording to how important they believed it was as apotential first aid guideline for helping a suicidal personThe response scale was 1 Essential 2 Important 3Donrsquot knowDepends 4 Unimportant 5 Should not beincluded The scale was purposefully asymmetricbecause only items with positive ratings were of interestfor the guidelines This scale has worked well in pre-vious guideline development work [7]At the end of each block of items the panel members

were asked to give any comments or add any additionalactions that were not included in the questionnaire Thesuggestions made by the panel members in response tothe open-ended questions were reviewed by the researchteam and used to construct new items Suggestions wereaccepted and added to Round 2 if they represented atruly new idea could be interpreted unambiguously andwere actions Suggestions were rejected if they werenear-duplicates of items in the questionnaire if theywere too specific too general or were more appropriateto therapy than first aid This was the place where cul-turally specific material could be introducedResponses were analysed to give the percentage of the

panel who rated an item as either ldquoessentialrdquo or ldquoimpor-tantrdquo Items for which there was at least 80 consensuswere included in the guidelines Items were re-rated if70-79 of the panel rated them as ldquoEssentialrdquo orldquoImportantrdquo A small number of items that receivedmore than 50 of ldquoDonrsquot knowDependsrdquo or ldquoNot surerdquoanswers were reworded to make them clearer and re-rated For example lsquocontact the personrsquos spiritual orreligious leaderrsquo became lsquocontact the personrsquos spiritualor religious leader if they have one lsquoItems that metneither condition were rejectedIn Round 2 a second questionnaire was prepared This

consisted of any new item that was generated from thecomments in Round 1 plus items that were positivelyrated by at least 70 of respondents but did not reachthe 80 criterion for inclusion Participants received anemail with an individualized link to the online survey anda word file that together with the latter items fed back astatistical summary of the items that were to be re-rated(ie their own original response to the item together withtotal percentages of endorsement of the item) They weretold that they did not have to change their responseswhen re-rating an item but that if they wished theywould have the opportunity to do so Panel memberswere asked to re-rate items which approached the desiredlevel of consensus and rate the new culturally specificitems after reading this feedback letter At the end of thisround any item that reached the 80 consensus criterionwas selected for inclusion in the guidelinesIn Round 3 any of the new items generated from the

open-ended questions in Round 1 that did not reach

consensus in Round 2 went back for re-rating (togetherwith a few items which received an excessively highnumber -more than 50- of ldquoDonrsquot knowdependsrdquoanswers) Participants received a statistical summary ofthe results as for Round 2 Again items that reachedthe required level of consensus were included in theguidelines

Cultural appropriateness of guidelinesAs described above the questionnaire on potential firstaid actions that was developed for English-speakingcountries (with a few additionalmodified items) was thestarting point for the Round 1 of the Delphi process forthis project At each round panel members were askedto suggest additional actions that were not covered inthe original questionnaire specifically to include itemsthat were relevant to local cultural circumstancesvalues etc These new items were rated in Rounds 2and 3 Panel members were also invited to comment onitems that were in the initial questionnaire that theyconsidered to be culturally irrelevant or unacceptable orthat would not be feasible because of the local healthsystem and other resources Moreover in the formationof the expert panels in each country we were careful toinclude as wide a representation (cultural and geo-graphic) of professionals as possible

EthicsEthics approval was obtained from the University ofMelbourne Human Research Ethics Committee (ProjectNo HREC 0605537)

ResultsSampleIn India 30 panel members were involved in Round 1(ie 68 of the experts who were invited to participate)25 in Round 2 and 23 in Round 3 All panel memberswere currently working in India The majority were psy-chiatrists (63) and psychologists (27) Two partici-pants were social workers and one was an occupationaltherapist The panel comprised of 17 males and 13females The majority (57) of the participants were inthe age range 40-49 years 3 were aged 18-29 years 6aged 30-39 years and 4 aged 50-59 yearsSome information was also collected on the clinical

experience of the panel members On average partici-pants reported that they had practiced in mental healthpsychiatry for 15 years (the shortest time was 2 yearsand the longest 30 years) Less of a quarter of the parti-cipants (23) received some formal education related totheir profession overseas (mainly in UK and one in Aus-tralia) Slightly over a third of the participants (37)reported having received a formal training specificallyon suicide preventionintervention However when

Colucci et al International Journal of Mental Health Systems 2010 44httpwwwijmhscomcontent414

Page 5 of 8

asked to state how well prepared they felt to assist a sui-cidal person 33 answered ldquoNot at allrdquo 23 ldquosomewhatpreparedrdquo 47 ldquomostly preparedrdquo and 27 ldquovery pre-paredrdquo Although participants generally felt prepared toassist a suicidal person in their opinion most people inIndia are not at all prepared (53) or somewhat pre-pared (43) Only one person believed others are mostlyprepared to assist

Items endorsementAfter three Delphi rounds there were 71 items thatwere rated as ldquoessentialrdquo or ldquoimportantrdquo by 80 or moreof the panel membersAt Round 2 30 new items suggested by participants

were added to the questionnaire The followings areexamples of such itemsbull An important warning sign for suicide is if a person

is saying they wish or intend to see or speak to someonewho is dead (eg a deceased family member)bull An important warning sign for suicide is if a person

is expressing in words or actions a sense of shame(eg from failure or loss)bull The first aider should not offer false hope or make

unrealistic promisesbull The first aider should not dismiss the personrsquos feel-

ings or compare their problems to the problems ofothersbull When talking to the suicidal person the first aider

should use the personrsquos belief systems and values toencourage them to change their mind about suicidebull The first aider should contact the elders in the per-

sonrsquos communityA number of responses to the Round 1 open-ended

questions did not meet criteria for creation of a newitem (eg they did not fit the definition of first aid ordid not suggest a clear action) or were commentssug-gestions The following are examples of the commentsand suggestions that did not generate new itemsbull ldquo The idea of suicide first aid does not exist in our

country It should be strongly encouraged at all levelsespecially in schools as the prevalence of suicide amongschool kids is alarming ()rdquobull ldquo I think that there should be more awareness about

ldquosuiciderdquo in our country so that people are sensitizedabout the ldquowarning signsrdquo of this person even before hecan attempt suicide In my culture since the family issuch an important support system they must beinformed right from the startrdquobull ldquo Psychiatrists psychologists and other mental health

professionals should receive training in how to handlesuicidal individuals victims of attempted suicide andsurvivors of suiciderdquobull ldquoIn our society individual freedom and opinion is

not as important as collective opinion Hence it is not

difficult to dissuade suicide by involving other indivi-duals in the family and society However the motivationof ldquoothersrdquo is not always highrdquobull ldquoIn eastern culture people are less likely to take the

issue seriously when one discloses onersquos intention tocommit suiciderdquoSee the Additional file 1 for a complete list of rated

statements including the percentage of panel membersendorsing each itemAt the end of the survey participants were asked their

opinions about the likely effectiveness of suicide firstaid using a 5-point Likert scale (from ldquodefinitely yesrdquo toldquodefinitely nordquo) All of them believed that if the firstaider does the right thing the risk of suicide can bereduced Substantial proportions of the respondentsthought that if the first aider does the wrong thing therisk of suicide can definitely (27) or probably (45) beincreased (21 answered ldquoDonrsquot knowdependsrdquo and14 ldquoProbably nordquo)The longer-term goal of the project is to use the

guidelines to develop implement and evaluate a trainingprogram on suicide first aid in India When asked ifthey thought members of the public should receive suchtraining 69 of panel members responded ldquodefinitelyyesrdquo and 27 ldquoprobably yesrdquo Only one respondentanswered ldquodonrsquot knowdependsrdquo

Development of statements that constitute the guidelinesThe output from the Delphi process was a set of agreedupon action statements The statements refer to actionsthat can be done by a mental health first aider To beusefully communicated these action statements havebeen woven into an integrated piece of text (instead of alist of ldquodosrdquo and ldquodonrsquotsrdquo) which become the SuicideFirst Aid Guidelines (see Additional File 2)

Participant feedback and modification of draft guidelinesThe draft guidelines were sent to all panel members fortheir comments and final endorsement Since the guide-lines were meant to be useful to members of the publicit was important to ensure that they were written to becomprehensible to the target non-professional reader-ship Feedback from panel members was explicitlysought on the structure and readability of the guidelinesand suggested improvements were incorporated in thefinal version

DiscussionThis project has demonstrated that it is possible toachieve consensus among mental health professionalson first aid strategies for suicidal thoughts and beha-viour and that the Delphi method is suitable for devel-oping consensus guidelines in India The method hasbeen similarly successful in Japan and the Philippines

Colucci et al International Journal of Mental Health Systems 2010 44httpwwwijmhscomcontent414

Page 6 of 8

We would suggest that guideline development studiesusing a similar method could be carried in a number ofother countries As well as developing country specificguidelines it will also be possible to develop guidelinesthat are appropriate for cultural minorities within acountry This approach has been used in Australia witha separate Delphi study undertaken to develop guide-lines for Aboriginal Australians using Aboriginal mentalhealth experts as panel members [22] and specificteaching programs have been developed for non-Englishspeaking immigrant communities [23]The next steps will be dissemination and use of the

guidelines for the purpose of increasing communitymembersrsquo ability to recognize the risk of suicide andundertake basic first aid actions A number of panelmembers in collaboration with our research team arecurrently seeking further funding so that the guidelinescan be translated into local languages and to examinewhether modifications are required for cultural minoritygroups The guidelines that have been developed willserve as a basis for detailed work on culturally appropri-ate guideline development in languages other than Eng-lish and for specific national and sub-national culturalgroupsThese guidelines can be used as a source of advice to

the public as a basis for determining the curriculum offirst aid training courses and as a standard againstwhich to evaluate the quality of existing materials andprograms The guidelines will inform the developmentof culturally appropriate training programs and informa-tion materials for how a member of the public can assistsomeone who is suicidal In some countries and areaswith less developed healthcare systems we believe theguidelines will be useful for primary health workers aswell as for members of the public It is anticipated thatthe results of this project will contribute to a programof training for community nurses and midwives and forvillage mental health workers to enable them to contri-bute more effectively to suicide prevention programs Itwill of course be necessary to rigorously evaluate theimpact of such training programs [23-25]

LimitationsOne limitation of this study is the small number ofpanel members although Delphi studies have been suc-cessfully run even with smaller groupsWe have developed these guidelines for India as a

whole while recognizing that India is characterised byremarkable cultural and linguistic diversity It is possiblethat the guidelines are not applicable to minority cul-tures within IndiaThe questionnaire was administered in English rather

than in the panelistsrsquo native languages This of courselimits the general applicability of the findings It is

possible that there would have been more culturally spe-cific responses if panelists had used their nativelanguageFuture studies should recruit broader and more

representative expert panels including where possibleprofessionals from all the relevant mental health disci-plines and consumer and carer representatives This ispresently difficult in many Asian countries becausethere are very few (if any) clinical psychologists psy-chiatric social workers occupational therapists andmental health nurses and the participation of consu-mers and carers in such research as members of anlsquoexpert panelrsquo rather than as research subjects is stilluncommon [10]Another limitation is that the inclusion of culturally

relevant material was dependent on panelists respondingto the open-ended questions and not every participantdid this This may have been in some cases due to lackof time or because the participants in this study werebetter able to read English than to write it It may alsobe because in questionnaires of all kinds that requireratings to be made respondents rarely take the opportu-nity to write comments or to make suggestions whenthe opportunity is given [10] However it must be notedthat compared to other similar mental health first aidguideline research a considerable number of suggestionsfor new items were given This might have been becauseof the emphasis in the instructions to participants onproviding suggestions based on participantsrsquo culturalsocial and religious settings in each section of thequestionnaire

ConclusionsThere is a growing awareness of suicide as a major pub-lic health problem even though there is a taboo inmany societies against discussing it openly [1] Develop-ing suicide first aid guidelines for community membersand training programs based on these might also con-tribute towards changing societyrsquos attitudes towards sui-cide and people who consider suicideThis study has demonstrated that it is possible to

reach consensus for the development of guidelines forIndia Although the guidelines were designed for thepublic they may also contain advice that might be help-ful to people working in health and welfare professionsWhere the guidelines are used as the basis for first aid

training efforts need to be made as far as possible toevaluate their impact on the first aiderrsquos helping beha-viour and on the recipients of the first aid This willassist researchers to develop an evidence base for mentalhealth first aid and suicide prevention initiativesIn a WHO news release [2] it was stated that ldquoItrsquos

important to realise that suicide is preventablerdquo By col-laborating with local experts to agree on a minimum set

Colucci et al International Journal of Mental Health Systems 2010 44httpwwwijmhscomcontent414

Page 7 of 8

of suicide first aid actions and by making such guide-lines freely and easily accessible to everyone we hope toconvey the message that suicide is preventable suicideis everyonersquos business and everyone can contribute toits reduction Members of the general public have a cru-cial role to play in suicide prevention Creating opportu-nities for the public to learn basic first aid actions andhow to implement them when needed is an importantstep towards more effective suicide prevention

Additional file 1 Table of data showing the items included in theDelphi survey and the endorsement levels from the Indian panelmembersClick here for file[ httpwwwbiomedcentralcomcontentsupplementary1752-4458-4-4-S1DOC ]

Additional file 2 First aid guidelines for India This file may bedistributed freely with the authorship and copyright details intact Pleasedo not alter the text or remove the authorship and copyright detailsClick here for file[ httpwwwbiomedcentralcomcontentsupplementary1752-4458-4-4-S2PDF ]

AcknowledgementsThe authors gratefully acknowledge the time effort and contribution of thefollowing panel members Pratheesh Kumar Sanjeev Jain Bernadette PereiraAchira Chatterjee Ramamurti Mangala Jai Ranjan Ram Mathew VargheseNeerja Choudhary Ankita Khanna Vikram Patel Alok Bajpai Abdul BariRakesh Lall Kavita Arora Gracy Andrews Lata Jacob Nishi Misra PadmavatiRamachandran Melvin Chagas Silva Subir Hajra Choudhary Updesh KumarSudipto Chatterjee Alok Sarin Rangaswamy Thara Prathama GuhaChaudhuri Sujit John Anil Rane Aniruddha Deb Santanu Goswami VivekBenegalFunding for the project was provided by the American Foundation forSuicide Prevention the Centre for International Mental Health (The Universityof Melbourne) Jorm and Kelly are supported by grants from the NationalHealth and Medical Research Council of Australia

Author details1Centre for International Mental Health Melbourne School of PopulationHealth The University of Melbourne Parkville Victoria 3010 Australia2Mental Health First Aid Training and Research Program ORYGEN YouthHealth Research Centre The University of Melbourne Parkville Victoria 3052Australia 3Sangath Centre 8411 Alto-Porvorim Goa 403521 India

Authorsrsquo contributionsEC recruited clinical experts revised the existing questionnaire prepared andadministered the on-line surveys for all three rounds analysed the dataprepared the draft and final guidelines and wrote the first draft of themanuscript CMK wrote the former questionnaire and contributed to therevised version supervised every stage of the project and co-wrote theguidelines HM co-wrote the grant application recruited the main localcollaborators and clinical experts reviewed the Round 1 questionnaire andthe guidelines AFJ co-wrote the grant application and developed themethod SC was the main local collaborator in the study and recruited themajority of the clinical experts All authors contributed to the writing of themanuscript and approved the final version

Competing interestsThe authors declare that they have no competing interests

Received 16 November 2009 Accepted 19 February 2010Published 19 February 2010

References1 WHO World Suicide Prevention Day [httpwwwwhointmediacentre

newsstatements2007s16en]2 WHO Suicide huge but preventable public health problem [httpwww

whointmediacentrenewsreleases2004pr61en]3 Tierney RJ Suicide intervention training evaluation a preliminary report

Crisis 1994 1569-764 Kitchener BA Jorm AF Mental health first aid training for the public

evaluation of effects on knowledge attitudes and helping behavior BMCPsychiatry 2002 210

5 Linstone HA Turoff M The Delphi method techniques and applications2002 [httpisnjitedupubsdelphibook]

6 Snyder-Halpern R Thompson CB Schaffer J Comparison of mailed vsInternet applications of the Delphi technique in clinical informaticsresearch Proc AMIA Symp 2000 809-813

7 Kelly CM Jorm AF Kitchener BA Langlands RL Development of mentalhealth first aid guidelines for suicidal ideation and behaviour a Delphistudy BMC Psychiatry 2008 817

8 Kelly CM Jorm AF Kitchener BA Langlands RL Development of mentalhealth first aid guidelines for deliberate non-suicidal self-injury a Delphistudy BMC Psychiatry 2008 862

9 Kelly CM Jorm AF Kitchener BA Development of mental health first aidguidelines for panic attacks a Delphi study BMC Psychiatry 2009 949

10 Jorm AF Minas H Langlands RL Kelly ML First aid guidelines forpsychosis in Asian countries A Delphi consensus study Int J Ment HealthSyst 2008 22

11 Langlands RL Jorm AF Kelly CM Kitchener BA First aid for depression aDelphi consensus study with consumers carers and clinicians J AffectDisord 2008 105157-165

12 Hart LM Jorm AF Paxton SJ Kelly CM Kitchener BA First Aid for EatingDisorders Eating Disorders 2009 17357-384

13 Colucci E The cultural facet of suicidal behaviour Its importance andneglect AeJAMH 2006 53

14 Colucci E Cultural issues in suicide risk assessment Suicidal BehaviorAssessment of People-at-risk New Delhi SAGEKumar U Mandal MK 2009

15 Colucci E Martin G Ethnocultural aspects of suicide in young people asystematic literature review Part 1 Rates and methods of youth suicideSuicide Life Threat Behav 2007 37197-221

16 Colucci E Martin G Ethnocultural aspects of suicide in young people asystematic literature review Part 2 Risk factors precipitating agentsand attitudes toward suicide Suicide Life Threat Behav 2007 37222-237

17 Hawgood J DeLeo D Suicide Prevention Skills Training Manual AnAccredited Training Program Brisbane Australia Griffith University 2002

18 Mental Health and Drug and Alcohol Office Mental Health for EmergencyDepartments - A Reference Guide Sydney NSW Department of Health2002

19 Colucci E Recognizing spirituality in the assessment and prevention ofsuicidal behaviour WCPRR 2008 377-95 [httpwwwwcprrorgpdf03-022008027795pdf]

20 Hasson F Keeney S McKenna H Research guidelines for the Delphisurvey technique J Adv Nurs 2000 321008-1015

21 SurveyMonkey [httpwwwsurveymonkeycom]22 Hart LM Jorm AF Kanowski LG Kelly CM Langlands RL Mental health first

aid for Indigenous Australians using Delphi consensus studies todevelop guidelines for culturally appropriate responses to mental healthproblems BMC Psychiatry 2009 947

23 Minas H Colucci E Jorm AF Evaluation of Mental Health First Aidtraining with members of the Vietnamese community in MelbourneIJMHS 2009 319

24 Jorm AF Kitchener BA Mugford SK Experiences in applying skills learnedin a Mental Health First Aid training course a qualitative study ofparticipantsrsquo stories BMC Psychiatry 2005 543

25 Kitchener BA Jorm AF Mental health first aid training review ofevaluation studies Australian and New Zealand Journal of Psychiatry 2006406-8

doi1011861752-4458-4-4Cite this article as Colucci et al Mental Health First Aid guidelines forhelping a suicidal person a Delphi consensus study in IndiaInternational Journal of Mental Health Systems 2010 44

Colucci et al International Journal of Mental Health Systems 2010 44httpwwwijmhscomcontent414

Page 8 of 8

grouped based on their common themes and used by aworking group to generate questionnaire items specify-ing what actions a first aider should take No judgmentswere made by the working group about the potentialusefulness of the statements Anything was includedthat fitted the definition of first aid even if contradic-tory to other statementsThe questionnaire developed for English-speaking

countries had 114 items each describing a potentialaction that a first aider could do which could be put tothe panel for rating These items covered the followingbroad areas identification of suicide risk assessing ser-iousness of suicide risk initial assistance talking with asuicidal person no-suicide contracts ensuring safetyconfidentiality and passing time during the crisis Theitems are shown in Additional File 1 For the Asianguidelines we added a few other items based upon theChief Investigatorrsquos previous work on suicide preventionin Asian countries (eg [1419]) Thus the initial ques-tionnaire contained 140 first aid action items plus 13questions on participantsrsquo socio-demographics experi-encetraining and opinions on suicide first aid Open-ended questions to generate additional culturally specificitems were also included Given that this was anexploratory project we used English-language question-naires because the cost of doing it in the expertsrsquo nativelanguages would have been prohibitive

Forming panelsA panel of Indian clinical experts currently working inIndia was formed The experts were recruited by SCHM and EC (see Figure 1) When invitation letterstogether with the Plain Language Statement were sent toprofessionals asking them to be involved they were alsoinvited to nominate any colleagues who they felt wouldbe appropriate panel members During the recruitmentprocess potential participants were informed that one ofthe selection criteria was to be fluent in written EnglishThe number of panel members in previous Delphi stu-dies has varied considerably from 15 to 60 [20] Weaimed to have a minimum of 25 members in a panel

Delphi processIn Round 1 of the Delphi process panel members wereasked to complete an on-line questionnaire This wasadministered using the SurveyMonkey application [21]with the option to complete it by email or paper mail ifthis was not possible (although no participant opted forthis alternative) The questionnaire consisted of a list offirst aid actions to rate Only actions that are do-able bymental health first aiders were included in the list of itemsto be rated Members of the expert panel were given thefollowing instructions to guide their judgments

ldquoThe following questionnaire asks about the bestway a member of the public can help someone whois thinking about or planning to suicide Mentalhealth first aid is defined as help given to someonewho is experiencing a mental health problem or isin a mental health-related crisis until professionalhelp is received or the crisis resolves It does notinclude counselling or therapy In the case of suicidemental health first aid is given until the person deci-des to accept professional help or decides againstsuicide People who offer mental health first aid maybe friends family members colleagues or acquain-tances They may or may not be involved in the per-sonrsquos life before or after offering first aid Forbrevity we will refer to the person offering assis-tance as ldquothe first aiderrdquo When completing thisquestionnaire you will read statements describingpossible actions that the first aider can take to assista suicidal individual You will be asked to rate howimportant each item is as a guideline for a firstaider Please rate as ldquoessentialrdquo or ldquoimportantrdquo thoseitems which you feel should guide most peoplemost of the time when assisting a suicidal personThe statements in this questionnaire were derivedfrom a search of both professional and lay literaturein English-speaking western countries Thereforethere will be actions which would be appropriate formembers of the public in your country which arenot included and there will be actions that may beappropriate in Western countries but not in yourcultural context At the bottom of each page thereis room for you to add suggestions Please considerthe cultural social and religious environment whereyou live and try to add some relevant suggestionson each page The more panel members add to thisquestionnaire the more relevant and useful theguidelines will be for each individual country Thankyou for taking the time to assist us in this importantsuicide prevention projectrdquo

The definition of mental health first aid given to thepanel was ldquoMental Health First Aid is the help providedto a person developing a mental health problem or in amental health crisis The first aid is given until appro-priate professional treatment is received or until the cri-sis resolvesrdquo This definition distinguishes a first aiderrsquosrole from that of a clinician In the case of a suicidalperson the first aider responds by getting professionalhelp for the person and supporting the person andensuring their safety until the crisis has passed Theguidelines needed to focus on the immediate preventionof suicide and not on solving the problems that lead tothe crisis

Colucci et al International Journal of Mental Health Systems 2010 44httpwwwijmhscomcontent414

Page 3 of 8

Figure 1 Stages in the guidelines development

Colucci et al International Journal of Mental Health Systems 2010 44httpwwwijmhscomcontent414

Page 4 of 8

Panelist members were asked to rate each statementaccording to how important they believed it was as apotential first aid guideline for helping a suicidal personThe response scale was 1 Essential 2 Important 3Donrsquot knowDepends 4 Unimportant 5 Should not beincluded The scale was purposefully asymmetricbecause only items with positive ratings were of interestfor the guidelines This scale has worked well in pre-vious guideline development work [7]At the end of each block of items the panel members

were asked to give any comments or add any additionalactions that were not included in the questionnaire Thesuggestions made by the panel members in response tothe open-ended questions were reviewed by the researchteam and used to construct new items Suggestions wereaccepted and added to Round 2 if they represented atruly new idea could be interpreted unambiguously andwere actions Suggestions were rejected if they werenear-duplicates of items in the questionnaire if theywere too specific too general or were more appropriateto therapy than first aid This was the place where cul-turally specific material could be introducedResponses were analysed to give the percentage of the

panel who rated an item as either ldquoessentialrdquo or ldquoimpor-tantrdquo Items for which there was at least 80 consensuswere included in the guidelines Items were re-rated if70-79 of the panel rated them as ldquoEssentialrdquo orldquoImportantrdquo A small number of items that receivedmore than 50 of ldquoDonrsquot knowDependsrdquo or ldquoNot surerdquoanswers were reworded to make them clearer and re-rated For example lsquocontact the personrsquos spiritual orreligious leaderrsquo became lsquocontact the personrsquos spiritualor religious leader if they have one lsquoItems that metneither condition were rejectedIn Round 2 a second questionnaire was prepared This

consisted of any new item that was generated from thecomments in Round 1 plus items that were positivelyrated by at least 70 of respondents but did not reachthe 80 criterion for inclusion Participants received anemail with an individualized link to the online survey anda word file that together with the latter items fed back astatistical summary of the items that were to be re-rated(ie their own original response to the item together withtotal percentages of endorsement of the item) They weretold that they did not have to change their responseswhen re-rating an item but that if they wished theywould have the opportunity to do so Panel memberswere asked to re-rate items which approached the desiredlevel of consensus and rate the new culturally specificitems after reading this feedback letter At the end of thisround any item that reached the 80 consensus criterionwas selected for inclusion in the guidelinesIn Round 3 any of the new items generated from the

open-ended questions in Round 1 that did not reach

consensus in Round 2 went back for re-rating (togetherwith a few items which received an excessively highnumber -more than 50- of ldquoDonrsquot knowdependsrdquoanswers) Participants received a statistical summary ofthe results as for Round 2 Again items that reachedthe required level of consensus were included in theguidelines

Cultural appropriateness of guidelinesAs described above the questionnaire on potential firstaid actions that was developed for English-speakingcountries (with a few additionalmodified items) was thestarting point for the Round 1 of the Delphi process forthis project At each round panel members were askedto suggest additional actions that were not covered inthe original questionnaire specifically to include itemsthat were relevant to local cultural circumstancesvalues etc These new items were rated in Rounds 2and 3 Panel members were also invited to comment onitems that were in the initial questionnaire that theyconsidered to be culturally irrelevant or unacceptable orthat would not be feasible because of the local healthsystem and other resources Moreover in the formationof the expert panels in each country we were careful toinclude as wide a representation (cultural and geo-graphic) of professionals as possible

EthicsEthics approval was obtained from the University ofMelbourne Human Research Ethics Committee (ProjectNo HREC 0605537)

ResultsSampleIn India 30 panel members were involved in Round 1(ie 68 of the experts who were invited to participate)25 in Round 2 and 23 in Round 3 All panel memberswere currently working in India The majority were psy-chiatrists (63) and psychologists (27) Two partici-pants were social workers and one was an occupationaltherapist The panel comprised of 17 males and 13females The majority (57) of the participants were inthe age range 40-49 years 3 were aged 18-29 years 6aged 30-39 years and 4 aged 50-59 yearsSome information was also collected on the clinical

experience of the panel members On average partici-pants reported that they had practiced in mental healthpsychiatry for 15 years (the shortest time was 2 yearsand the longest 30 years) Less of a quarter of the parti-cipants (23) received some formal education related totheir profession overseas (mainly in UK and one in Aus-tralia) Slightly over a third of the participants (37)reported having received a formal training specificallyon suicide preventionintervention However when

Colucci et al International Journal of Mental Health Systems 2010 44httpwwwijmhscomcontent414

Page 5 of 8

asked to state how well prepared they felt to assist a sui-cidal person 33 answered ldquoNot at allrdquo 23 ldquosomewhatpreparedrdquo 47 ldquomostly preparedrdquo and 27 ldquovery pre-paredrdquo Although participants generally felt prepared toassist a suicidal person in their opinion most people inIndia are not at all prepared (53) or somewhat pre-pared (43) Only one person believed others are mostlyprepared to assist

Items endorsementAfter three Delphi rounds there were 71 items thatwere rated as ldquoessentialrdquo or ldquoimportantrdquo by 80 or moreof the panel membersAt Round 2 30 new items suggested by participants

were added to the questionnaire The followings areexamples of such itemsbull An important warning sign for suicide is if a person

is saying they wish or intend to see or speak to someonewho is dead (eg a deceased family member)bull An important warning sign for suicide is if a person

is expressing in words or actions a sense of shame(eg from failure or loss)bull The first aider should not offer false hope or make

unrealistic promisesbull The first aider should not dismiss the personrsquos feel-

ings or compare their problems to the problems ofothersbull When talking to the suicidal person the first aider

should use the personrsquos belief systems and values toencourage them to change their mind about suicidebull The first aider should contact the elders in the per-

sonrsquos communityA number of responses to the Round 1 open-ended

questions did not meet criteria for creation of a newitem (eg they did not fit the definition of first aid ordid not suggest a clear action) or were commentssug-gestions The following are examples of the commentsand suggestions that did not generate new itemsbull ldquo The idea of suicide first aid does not exist in our

country It should be strongly encouraged at all levelsespecially in schools as the prevalence of suicide amongschool kids is alarming ()rdquobull ldquo I think that there should be more awareness about

ldquosuiciderdquo in our country so that people are sensitizedabout the ldquowarning signsrdquo of this person even before hecan attempt suicide In my culture since the family issuch an important support system they must beinformed right from the startrdquobull ldquo Psychiatrists psychologists and other mental health

professionals should receive training in how to handlesuicidal individuals victims of attempted suicide andsurvivors of suiciderdquobull ldquoIn our society individual freedom and opinion is

not as important as collective opinion Hence it is not

difficult to dissuade suicide by involving other indivi-duals in the family and society However the motivationof ldquoothersrdquo is not always highrdquobull ldquoIn eastern culture people are less likely to take the

issue seriously when one discloses onersquos intention tocommit suiciderdquoSee the Additional file 1 for a complete list of rated

statements including the percentage of panel membersendorsing each itemAt the end of the survey participants were asked their

opinions about the likely effectiveness of suicide firstaid using a 5-point Likert scale (from ldquodefinitely yesrdquo toldquodefinitely nordquo) All of them believed that if the firstaider does the right thing the risk of suicide can bereduced Substantial proportions of the respondentsthought that if the first aider does the wrong thing therisk of suicide can definitely (27) or probably (45) beincreased (21 answered ldquoDonrsquot knowdependsrdquo and14 ldquoProbably nordquo)The longer-term goal of the project is to use the

guidelines to develop implement and evaluate a trainingprogram on suicide first aid in India When asked ifthey thought members of the public should receive suchtraining 69 of panel members responded ldquodefinitelyyesrdquo and 27 ldquoprobably yesrdquo Only one respondentanswered ldquodonrsquot knowdependsrdquo

Development of statements that constitute the guidelinesThe output from the Delphi process was a set of agreedupon action statements The statements refer to actionsthat can be done by a mental health first aider To beusefully communicated these action statements havebeen woven into an integrated piece of text (instead of alist of ldquodosrdquo and ldquodonrsquotsrdquo) which become the SuicideFirst Aid Guidelines (see Additional File 2)

Participant feedback and modification of draft guidelinesThe draft guidelines were sent to all panel members fortheir comments and final endorsement Since the guide-lines were meant to be useful to members of the publicit was important to ensure that they were written to becomprehensible to the target non-professional reader-ship Feedback from panel members was explicitlysought on the structure and readability of the guidelinesand suggested improvements were incorporated in thefinal version

DiscussionThis project has demonstrated that it is possible toachieve consensus among mental health professionalson first aid strategies for suicidal thoughts and beha-viour and that the Delphi method is suitable for devel-oping consensus guidelines in India The method hasbeen similarly successful in Japan and the Philippines

Colucci et al International Journal of Mental Health Systems 2010 44httpwwwijmhscomcontent414

Page 6 of 8

We would suggest that guideline development studiesusing a similar method could be carried in a number ofother countries As well as developing country specificguidelines it will also be possible to develop guidelinesthat are appropriate for cultural minorities within acountry This approach has been used in Australia witha separate Delphi study undertaken to develop guide-lines for Aboriginal Australians using Aboriginal mentalhealth experts as panel members [22] and specificteaching programs have been developed for non-Englishspeaking immigrant communities [23]The next steps will be dissemination and use of the

guidelines for the purpose of increasing communitymembersrsquo ability to recognize the risk of suicide andundertake basic first aid actions A number of panelmembers in collaboration with our research team arecurrently seeking further funding so that the guidelinescan be translated into local languages and to examinewhether modifications are required for cultural minoritygroups The guidelines that have been developed willserve as a basis for detailed work on culturally appropri-ate guideline development in languages other than Eng-lish and for specific national and sub-national culturalgroupsThese guidelines can be used as a source of advice to

the public as a basis for determining the curriculum offirst aid training courses and as a standard againstwhich to evaluate the quality of existing materials andprograms The guidelines will inform the developmentof culturally appropriate training programs and informa-tion materials for how a member of the public can assistsomeone who is suicidal In some countries and areaswith less developed healthcare systems we believe theguidelines will be useful for primary health workers aswell as for members of the public It is anticipated thatthe results of this project will contribute to a programof training for community nurses and midwives and forvillage mental health workers to enable them to contri-bute more effectively to suicide prevention programs Itwill of course be necessary to rigorously evaluate theimpact of such training programs [23-25]

LimitationsOne limitation of this study is the small number ofpanel members although Delphi studies have been suc-cessfully run even with smaller groupsWe have developed these guidelines for India as a

whole while recognizing that India is characterised byremarkable cultural and linguistic diversity It is possiblethat the guidelines are not applicable to minority cul-tures within IndiaThe questionnaire was administered in English rather

than in the panelistsrsquo native languages This of courselimits the general applicability of the findings It is

possible that there would have been more culturally spe-cific responses if panelists had used their nativelanguageFuture studies should recruit broader and more

representative expert panels including where possibleprofessionals from all the relevant mental health disci-plines and consumer and carer representatives This ispresently difficult in many Asian countries becausethere are very few (if any) clinical psychologists psy-chiatric social workers occupational therapists andmental health nurses and the participation of consu-mers and carers in such research as members of anlsquoexpert panelrsquo rather than as research subjects is stilluncommon [10]Another limitation is that the inclusion of culturally

relevant material was dependent on panelists respondingto the open-ended questions and not every participantdid this This may have been in some cases due to lackof time or because the participants in this study werebetter able to read English than to write it It may alsobe because in questionnaires of all kinds that requireratings to be made respondents rarely take the opportu-nity to write comments or to make suggestions whenthe opportunity is given [10] However it must be notedthat compared to other similar mental health first aidguideline research a considerable number of suggestionsfor new items were given This might have been becauseof the emphasis in the instructions to participants onproviding suggestions based on participantsrsquo culturalsocial and religious settings in each section of thequestionnaire

ConclusionsThere is a growing awareness of suicide as a major pub-lic health problem even though there is a taboo inmany societies against discussing it openly [1] Develop-ing suicide first aid guidelines for community membersand training programs based on these might also con-tribute towards changing societyrsquos attitudes towards sui-cide and people who consider suicideThis study has demonstrated that it is possible to

reach consensus for the development of guidelines forIndia Although the guidelines were designed for thepublic they may also contain advice that might be help-ful to people working in health and welfare professionsWhere the guidelines are used as the basis for first aid

training efforts need to be made as far as possible toevaluate their impact on the first aiderrsquos helping beha-viour and on the recipients of the first aid This willassist researchers to develop an evidence base for mentalhealth first aid and suicide prevention initiativesIn a WHO news release [2] it was stated that ldquoItrsquos

important to realise that suicide is preventablerdquo By col-laborating with local experts to agree on a minimum set

Colucci et al International Journal of Mental Health Systems 2010 44httpwwwijmhscomcontent414

Page 7 of 8

of suicide first aid actions and by making such guide-lines freely and easily accessible to everyone we hope toconvey the message that suicide is preventable suicideis everyonersquos business and everyone can contribute toits reduction Members of the general public have a cru-cial role to play in suicide prevention Creating opportu-nities for the public to learn basic first aid actions andhow to implement them when needed is an importantstep towards more effective suicide prevention

Additional file 1 Table of data showing the items included in theDelphi survey and the endorsement levels from the Indian panelmembersClick here for file[ httpwwwbiomedcentralcomcontentsupplementary1752-4458-4-4-S1DOC ]

Additional file 2 First aid guidelines for India This file may bedistributed freely with the authorship and copyright details intact Pleasedo not alter the text or remove the authorship and copyright detailsClick here for file[ httpwwwbiomedcentralcomcontentsupplementary1752-4458-4-4-S2PDF ]

AcknowledgementsThe authors gratefully acknowledge the time effort and contribution of thefollowing panel members Pratheesh Kumar Sanjeev Jain Bernadette PereiraAchira Chatterjee Ramamurti Mangala Jai Ranjan Ram Mathew VargheseNeerja Choudhary Ankita Khanna Vikram Patel Alok Bajpai Abdul BariRakesh Lall Kavita Arora Gracy Andrews Lata Jacob Nishi Misra PadmavatiRamachandran Melvin Chagas Silva Subir Hajra Choudhary Updesh KumarSudipto Chatterjee Alok Sarin Rangaswamy Thara Prathama GuhaChaudhuri Sujit John Anil Rane Aniruddha Deb Santanu Goswami VivekBenegalFunding for the project was provided by the American Foundation forSuicide Prevention the Centre for International Mental Health (The Universityof Melbourne) Jorm and Kelly are supported by grants from the NationalHealth and Medical Research Council of Australia

Author details1Centre for International Mental Health Melbourne School of PopulationHealth The University of Melbourne Parkville Victoria 3010 Australia2Mental Health First Aid Training and Research Program ORYGEN YouthHealth Research Centre The University of Melbourne Parkville Victoria 3052Australia 3Sangath Centre 8411 Alto-Porvorim Goa 403521 India

Authorsrsquo contributionsEC recruited clinical experts revised the existing questionnaire prepared andadministered the on-line surveys for all three rounds analysed the dataprepared the draft and final guidelines and wrote the first draft of themanuscript CMK wrote the former questionnaire and contributed to therevised version supervised every stage of the project and co-wrote theguidelines HM co-wrote the grant application recruited the main localcollaborators and clinical experts reviewed the Round 1 questionnaire andthe guidelines AFJ co-wrote the grant application and developed themethod SC was the main local collaborator in the study and recruited themajority of the clinical experts All authors contributed to the writing of themanuscript and approved the final version

Competing interestsThe authors declare that they have no competing interests

Received 16 November 2009 Accepted 19 February 2010Published 19 February 2010

References1 WHO World Suicide Prevention Day [httpwwwwhointmediacentre

newsstatements2007s16en]2 WHO Suicide huge but preventable public health problem [httpwww

whointmediacentrenewsreleases2004pr61en]3 Tierney RJ Suicide intervention training evaluation a preliminary report

Crisis 1994 1569-764 Kitchener BA Jorm AF Mental health first aid training for the public

evaluation of effects on knowledge attitudes and helping behavior BMCPsychiatry 2002 210

5 Linstone HA Turoff M The Delphi method techniques and applications2002 [httpisnjitedupubsdelphibook]

6 Snyder-Halpern R Thompson CB Schaffer J Comparison of mailed vsInternet applications of the Delphi technique in clinical informaticsresearch Proc AMIA Symp 2000 809-813

7 Kelly CM Jorm AF Kitchener BA Langlands RL Development of mentalhealth first aid guidelines for suicidal ideation and behaviour a Delphistudy BMC Psychiatry 2008 817

8 Kelly CM Jorm AF Kitchener BA Langlands RL Development of mentalhealth first aid guidelines for deliberate non-suicidal self-injury a Delphistudy BMC Psychiatry 2008 862

9 Kelly CM Jorm AF Kitchener BA Development of mental health first aidguidelines for panic attacks a Delphi study BMC Psychiatry 2009 949

10 Jorm AF Minas H Langlands RL Kelly ML First aid guidelines forpsychosis in Asian countries A Delphi consensus study Int J Ment HealthSyst 2008 22

11 Langlands RL Jorm AF Kelly CM Kitchener BA First aid for depression aDelphi consensus study with consumers carers and clinicians J AffectDisord 2008 105157-165

12 Hart LM Jorm AF Paxton SJ Kelly CM Kitchener BA First Aid for EatingDisorders Eating Disorders 2009 17357-384

13 Colucci E The cultural facet of suicidal behaviour Its importance andneglect AeJAMH 2006 53

14 Colucci E Cultural issues in suicide risk assessment Suicidal BehaviorAssessment of People-at-risk New Delhi SAGEKumar U Mandal MK 2009

15 Colucci E Martin G Ethnocultural aspects of suicide in young people asystematic literature review Part 1 Rates and methods of youth suicideSuicide Life Threat Behav 2007 37197-221

16 Colucci E Martin G Ethnocultural aspects of suicide in young people asystematic literature review Part 2 Risk factors precipitating agentsand attitudes toward suicide Suicide Life Threat Behav 2007 37222-237

17 Hawgood J DeLeo D Suicide Prevention Skills Training Manual AnAccredited Training Program Brisbane Australia Griffith University 2002

18 Mental Health and Drug and Alcohol Office Mental Health for EmergencyDepartments - A Reference Guide Sydney NSW Department of Health2002

19 Colucci E Recognizing spirituality in the assessment and prevention ofsuicidal behaviour WCPRR 2008 377-95 [httpwwwwcprrorgpdf03-022008027795pdf]

20 Hasson F Keeney S McKenna H Research guidelines for the Delphisurvey technique J Adv Nurs 2000 321008-1015

21 SurveyMonkey [httpwwwsurveymonkeycom]22 Hart LM Jorm AF Kanowski LG Kelly CM Langlands RL Mental health first

aid for Indigenous Australians using Delphi consensus studies todevelop guidelines for culturally appropriate responses to mental healthproblems BMC Psychiatry 2009 947

23 Minas H Colucci E Jorm AF Evaluation of Mental Health First Aidtraining with members of the Vietnamese community in MelbourneIJMHS 2009 319

24 Jorm AF Kitchener BA Mugford SK Experiences in applying skills learnedin a Mental Health First Aid training course a qualitative study ofparticipantsrsquo stories BMC Psychiatry 2005 543

25 Kitchener BA Jorm AF Mental health first aid training review ofevaluation studies Australian and New Zealand Journal of Psychiatry 2006406-8

doi1011861752-4458-4-4Cite this article as Colucci et al Mental Health First Aid guidelines forhelping a suicidal person a Delphi consensus study in IndiaInternational Journal of Mental Health Systems 2010 44

Colucci et al International Journal of Mental Health Systems 2010 44httpwwwijmhscomcontent414

Page 8 of 8

Figure 1 Stages in the guidelines development

Colucci et al International Journal of Mental Health Systems 2010 44httpwwwijmhscomcontent414

Page 4 of 8

Panelist members were asked to rate each statementaccording to how important they believed it was as apotential first aid guideline for helping a suicidal personThe response scale was 1 Essential 2 Important 3Donrsquot knowDepends 4 Unimportant 5 Should not beincluded The scale was purposefully asymmetricbecause only items with positive ratings were of interestfor the guidelines This scale has worked well in pre-vious guideline development work [7]At the end of each block of items the panel members

were asked to give any comments or add any additionalactions that were not included in the questionnaire Thesuggestions made by the panel members in response tothe open-ended questions were reviewed by the researchteam and used to construct new items Suggestions wereaccepted and added to Round 2 if they represented atruly new idea could be interpreted unambiguously andwere actions Suggestions were rejected if they werenear-duplicates of items in the questionnaire if theywere too specific too general or were more appropriateto therapy than first aid This was the place where cul-turally specific material could be introducedResponses were analysed to give the percentage of the

panel who rated an item as either ldquoessentialrdquo or ldquoimpor-tantrdquo Items for which there was at least 80 consensuswere included in the guidelines Items were re-rated if70-79 of the panel rated them as ldquoEssentialrdquo orldquoImportantrdquo A small number of items that receivedmore than 50 of ldquoDonrsquot knowDependsrdquo or ldquoNot surerdquoanswers were reworded to make them clearer and re-rated For example lsquocontact the personrsquos spiritual orreligious leaderrsquo became lsquocontact the personrsquos spiritualor religious leader if they have one lsquoItems that metneither condition were rejectedIn Round 2 a second questionnaire was prepared This

consisted of any new item that was generated from thecomments in Round 1 plus items that were positivelyrated by at least 70 of respondents but did not reachthe 80 criterion for inclusion Participants received anemail with an individualized link to the online survey anda word file that together with the latter items fed back astatistical summary of the items that were to be re-rated(ie their own original response to the item together withtotal percentages of endorsement of the item) They weretold that they did not have to change their responseswhen re-rating an item but that if they wished theywould have the opportunity to do so Panel memberswere asked to re-rate items which approached the desiredlevel of consensus and rate the new culturally specificitems after reading this feedback letter At the end of thisround any item that reached the 80 consensus criterionwas selected for inclusion in the guidelinesIn Round 3 any of the new items generated from the

open-ended questions in Round 1 that did not reach

consensus in Round 2 went back for re-rating (togetherwith a few items which received an excessively highnumber -more than 50- of ldquoDonrsquot knowdependsrdquoanswers) Participants received a statistical summary ofthe results as for Round 2 Again items that reachedthe required level of consensus were included in theguidelines

Cultural appropriateness of guidelinesAs described above the questionnaire on potential firstaid actions that was developed for English-speakingcountries (with a few additionalmodified items) was thestarting point for the Round 1 of the Delphi process forthis project At each round panel members were askedto suggest additional actions that were not covered inthe original questionnaire specifically to include itemsthat were relevant to local cultural circumstancesvalues etc These new items were rated in Rounds 2and 3 Panel members were also invited to comment onitems that were in the initial questionnaire that theyconsidered to be culturally irrelevant or unacceptable orthat would not be feasible because of the local healthsystem and other resources Moreover in the formationof the expert panels in each country we were careful toinclude as wide a representation (cultural and geo-graphic) of professionals as possible

EthicsEthics approval was obtained from the University ofMelbourne Human Research Ethics Committee (ProjectNo HREC 0605537)

ResultsSampleIn India 30 panel members were involved in Round 1(ie 68 of the experts who were invited to participate)25 in Round 2 and 23 in Round 3 All panel memberswere currently working in India The majority were psy-chiatrists (63) and psychologists (27) Two partici-pants were social workers and one was an occupationaltherapist The panel comprised of 17 males and 13females The majority (57) of the participants were inthe age range 40-49 years 3 were aged 18-29 years 6aged 30-39 years and 4 aged 50-59 yearsSome information was also collected on the clinical

experience of the panel members On average partici-pants reported that they had practiced in mental healthpsychiatry for 15 years (the shortest time was 2 yearsand the longest 30 years) Less of a quarter of the parti-cipants (23) received some formal education related totheir profession overseas (mainly in UK and one in Aus-tralia) Slightly over a third of the participants (37)reported having received a formal training specificallyon suicide preventionintervention However when

Colucci et al International Journal of Mental Health Systems 2010 44httpwwwijmhscomcontent414

Page 5 of 8

asked to state how well prepared they felt to assist a sui-cidal person 33 answered ldquoNot at allrdquo 23 ldquosomewhatpreparedrdquo 47 ldquomostly preparedrdquo and 27 ldquovery pre-paredrdquo Although participants generally felt prepared toassist a suicidal person in their opinion most people inIndia are not at all prepared (53) or somewhat pre-pared (43) Only one person believed others are mostlyprepared to assist

Items endorsementAfter three Delphi rounds there were 71 items thatwere rated as ldquoessentialrdquo or ldquoimportantrdquo by 80 or moreof the panel membersAt Round 2 30 new items suggested by participants

were added to the questionnaire The followings areexamples of such itemsbull An important warning sign for suicide is if a person

is saying they wish or intend to see or speak to someonewho is dead (eg a deceased family member)bull An important warning sign for suicide is if a person

is expressing in words or actions a sense of shame(eg from failure or loss)bull The first aider should not offer false hope or make

unrealistic promisesbull The first aider should not dismiss the personrsquos feel-

ings or compare their problems to the problems ofothersbull When talking to the suicidal person the first aider

should use the personrsquos belief systems and values toencourage them to change their mind about suicidebull The first aider should contact the elders in the per-

sonrsquos communityA number of responses to the Round 1 open-ended

questions did not meet criteria for creation of a newitem (eg they did not fit the definition of first aid ordid not suggest a clear action) or were commentssug-gestions The following are examples of the commentsand suggestions that did not generate new itemsbull ldquo The idea of suicide first aid does not exist in our

country It should be strongly encouraged at all levelsespecially in schools as the prevalence of suicide amongschool kids is alarming ()rdquobull ldquo I think that there should be more awareness about

ldquosuiciderdquo in our country so that people are sensitizedabout the ldquowarning signsrdquo of this person even before hecan attempt suicide In my culture since the family issuch an important support system they must beinformed right from the startrdquobull ldquo Psychiatrists psychologists and other mental health

professionals should receive training in how to handlesuicidal individuals victims of attempted suicide andsurvivors of suiciderdquobull ldquoIn our society individual freedom and opinion is

not as important as collective opinion Hence it is not

difficult to dissuade suicide by involving other indivi-duals in the family and society However the motivationof ldquoothersrdquo is not always highrdquobull ldquoIn eastern culture people are less likely to take the

issue seriously when one discloses onersquos intention tocommit suiciderdquoSee the Additional file 1 for a complete list of rated

statements including the percentage of panel membersendorsing each itemAt the end of the survey participants were asked their

opinions about the likely effectiveness of suicide firstaid using a 5-point Likert scale (from ldquodefinitely yesrdquo toldquodefinitely nordquo) All of them believed that if the firstaider does the right thing the risk of suicide can bereduced Substantial proportions of the respondentsthought that if the first aider does the wrong thing therisk of suicide can definitely (27) or probably (45) beincreased (21 answered ldquoDonrsquot knowdependsrdquo and14 ldquoProbably nordquo)The longer-term goal of the project is to use the

guidelines to develop implement and evaluate a trainingprogram on suicide first aid in India When asked ifthey thought members of the public should receive suchtraining 69 of panel members responded ldquodefinitelyyesrdquo and 27 ldquoprobably yesrdquo Only one respondentanswered ldquodonrsquot knowdependsrdquo

Development of statements that constitute the guidelinesThe output from the Delphi process was a set of agreedupon action statements The statements refer to actionsthat can be done by a mental health first aider To beusefully communicated these action statements havebeen woven into an integrated piece of text (instead of alist of ldquodosrdquo and ldquodonrsquotsrdquo) which become the SuicideFirst Aid Guidelines (see Additional File 2)

Participant feedback and modification of draft guidelinesThe draft guidelines were sent to all panel members fortheir comments and final endorsement Since the guide-lines were meant to be useful to members of the publicit was important to ensure that they were written to becomprehensible to the target non-professional reader-ship Feedback from panel members was explicitlysought on the structure and readability of the guidelinesand suggested improvements were incorporated in thefinal version

DiscussionThis project has demonstrated that it is possible toachieve consensus among mental health professionalson first aid strategies for suicidal thoughts and beha-viour and that the Delphi method is suitable for devel-oping consensus guidelines in India The method hasbeen similarly successful in Japan and the Philippines

Colucci et al International Journal of Mental Health Systems 2010 44httpwwwijmhscomcontent414

Page 6 of 8

We would suggest that guideline development studiesusing a similar method could be carried in a number ofother countries As well as developing country specificguidelines it will also be possible to develop guidelinesthat are appropriate for cultural minorities within acountry This approach has been used in Australia witha separate Delphi study undertaken to develop guide-lines for Aboriginal Australians using Aboriginal mentalhealth experts as panel members [22] and specificteaching programs have been developed for non-Englishspeaking immigrant communities [23]The next steps will be dissemination and use of the

guidelines for the purpose of increasing communitymembersrsquo ability to recognize the risk of suicide andundertake basic first aid actions A number of panelmembers in collaboration with our research team arecurrently seeking further funding so that the guidelinescan be translated into local languages and to examinewhether modifications are required for cultural minoritygroups The guidelines that have been developed willserve as a basis for detailed work on culturally appropri-ate guideline development in languages other than Eng-lish and for specific national and sub-national culturalgroupsThese guidelines can be used as a source of advice to

the public as a basis for determining the curriculum offirst aid training courses and as a standard againstwhich to evaluate the quality of existing materials andprograms The guidelines will inform the developmentof culturally appropriate training programs and informa-tion materials for how a member of the public can assistsomeone who is suicidal In some countries and areaswith less developed healthcare systems we believe theguidelines will be useful for primary health workers aswell as for members of the public It is anticipated thatthe results of this project will contribute to a programof training for community nurses and midwives and forvillage mental health workers to enable them to contri-bute more effectively to suicide prevention programs Itwill of course be necessary to rigorously evaluate theimpact of such training programs [23-25]

LimitationsOne limitation of this study is the small number ofpanel members although Delphi studies have been suc-cessfully run even with smaller groupsWe have developed these guidelines for India as a

whole while recognizing that India is characterised byremarkable cultural and linguistic diversity It is possiblethat the guidelines are not applicable to minority cul-tures within IndiaThe questionnaire was administered in English rather

than in the panelistsrsquo native languages This of courselimits the general applicability of the findings It is

possible that there would have been more culturally spe-cific responses if panelists had used their nativelanguageFuture studies should recruit broader and more

representative expert panels including where possibleprofessionals from all the relevant mental health disci-plines and consumer and carer representatives This ispresently difficult in many Asian countries becausethere are very few (if any) clinical psychologists psy-chiatric social workers occupational therapists andmental health nurses and the participation of consu-mers and carers in such research as members of anlsquoexpert panelrsquo rather than as research subjects is stilluncommon [10]Another limitation is that the inclusion of culturally

relevant material was dependent on panelists respondingto the open-ended questions and not every participantdid this This may have been in some cases due to lackof time or because the participants in this study werebetter able to read English than to write it It may alsobe because in questionnaires of all kinds that requireratings to be made respondents rarely take the opportu-nity to write comments or to make suggestions whenthe opportunity is given [10] However it must be notedthat compared to other similar mental health first aidguideline research a considerable number of suggestionsfor new items were given This might have been becauseof the emphasis in the instructions to participants onproviding suggestions based on participantsrsquo culturalsocial and religious settings in each section of thequestionnaire

ConclusionsThere is a growing awareness of suicide as a major pub-lic health problem even though there is a taboo inmany societies against discussing it openly [1] Develop-ing suicide first aid guidelines for community membersand training programs based on these might also con-tribute towards changing societyrsquos attitudes towards sui-cide and people who consider suicideThis study has demonstrated that it is possible to

reach consensus for the development of guidelines forIndia Although the guidelines were designed for thepublic they may also contain advice that might be help-ful to people working in health and welfare professionsWhere the guidelines are used as the basis for first aid

training efforts need to be made as far as possible toevaluate their impact on the first aiderrsquos helping beha-viour and on the recipients of the first aid This willassist researchers to develop an evidence base for mentalhealth first aid and suicide prevention initiativesIn a WHO news release [2] it was stated that ldquoItrsquos

important to realise that suicide is preventablerdquo By col-laborating with local experts to agree on a minimum set

Colucci et al International Journal of Mental Health Systems 2010 44httpwwwijmhscomcontent414

Page 7 of 8

of suicide first aid actions and by making such guide-lines freely and easily accessible to everyone we hope toconvey the message that suicide is preventable suicideis everyonersquos business and everyone can contribute toits reduction Members of the general public have a cru-cial role to play in suicide prevention Creating opportu-nities for the public to learn basic first aid actions andhow to implement them when needed is an importantstep towards more effective suicide prevention

Additional file 1 Table of data showing the items included in theDelphi survey and the endorsement levels from the Indian panelmembersClick here for file[ httpwwwbiomedcentralcomcontentsupplementary1752-4458-4-4-S1DOC ]

Additional file 2 First aid guidelines for India This file may bedistributed freely with the authorship and copyright details intact Pleasedo not alter the text or remove the authorship and copyright detailsClick here for file[ httpwwwbiomedcentralcomcontentsupplementary1752-4458-4-4-S2PDF ]

AcknowledgementsThe authors gratefully acknowledge the time effort and contribution of thefollowing panel members Pratheesh Kumar Sanjeev Jain Bernadette PereiraAchira Chatterjee Ramamurti Mangala Jai Ranjan Ram Mathew VargheseNeerja Choudhary Ankita Khanna Vikram Patel Alok Bajpai Abdul BariRakesh Lall Kavita Arora Gracy Andrews Lata Jacob Nishi Misra PadmavatiRamachandran Melvin Chagas Silva Subir Hajra Choudhary Updesh KumarSudipto Chatterjee Alok Sarin Rangaswamy Thara Prathama GuhaChaudhuri Sujit John Anil Rane Aniruddha Deb Santanu Goswami VivekBenegalFunding for the project was provided by the American Foundation forSuicide Prevention the Centre for International Mental Health (The Universityof Melbourne) Jorm and Kelly are supported by grants from the NationalHealth and Medical Research Council of Australia

Author details1Centre for International Mental Health Melbourne School of PopulationHealth The University of Melbourne Parkville Victoria 3010 Australia2Mental Health First Aid Training and Research Program ORYGEN YouthHealth Research Centre The University of Melbourne Parkville Victoria 3052Australia 3Sangath Centre 8411 Alto-Porvorim Goa 403521 India

Authorsrsquo contributionsEC recruited clinical experts revised the existing questionnaire prepared andadministered the on-line surveys for all three rounds analysed the dataprepared the draft and final guidelines and wrote the first draft of themanuscript CMK wrote the former questionnaire and contributed to therevised version supervised every stage of the project and co-wrote theguidelines HM co-wrote the grant application recruited the main localcollaborators and clinical experts reviewed the Round 1 questionnaire andthe guidelines AFJ co-wrote the grant application and developed themethod SC was the main local collaborator in the study and recruited themajority of the clinical experts All authors contributed to the writing of themanuscript and approved the final version

Competing interestsThe authors declare that they have no competing interests

Received 16 November 2009 Accepted 19 February 2010Published 19 February 2010

References1 WHO World Suicide Prevention Day [httpwwwwhointmediacentre

newsstatements2007s16en]2 WHO Suicide huge but preventable public health problem [httpwww

whointmediacentrenewsreleases2004pr61en]3 Tierney RJ Suicide intervention training evaluation a preliminary report

Crisis 1994 1569-764 Kitchener BA Jorm AF Mental health first aid training for the public

evaluation of effects on knowledge attitudes and helping behavior BMCPsychiatry 2002 210

5 Linstone HA Turoff M The Delphi method techniques and applications2002 [httpisnjitedupubsdelphibook]

6 Snyder-Halpern R Thompson CB Schaffer J Comparison of mailed vsInternet applications of the Delphi technique in clinical informaticsresearch Proc AMIA Symp 2000 809-813

7 Kelly CM Jorm AF Kitchener BA Langlands RL Development of mentalhealth first aid guidelines for suicidal ideation and behaviour a Delphistudy BMC Psychiatry 2008 817

8 Kelly CM Jorm AF Kitchener BA Langlands RL Development of mentalhealth first aid guidelines for deliberate non-suicidal self-injury a Delphistudy BMC Psychiatry 2008 862

9 Kelly CM Jorm AF Kitchener BA Development of mental health first aidguidelines for panic attacks a Delphi study BMC Psychiatry 2009 949

10 Jorm AF Minas H Langlands RL Kelly ML First aid guidelines forpsychosis in Asian countries A Delphi consensus study Int J Ment HealthSyst 2008 22

11 Langlands RL Jorm AF Kelly CM Kitchener BA First aid for depression aDelphi consensus study with consumers carers and clinicians J AffectDisord 2008 105157-165

12 Hart LM Jorm AF Paxton SJ Kelly CM Kitchener BA First Aid for EatingDisorders Eating Disorders 2009 17357-384

13 Colucci E The cultural facet of suicidal behaviour Its importance andneglect AeJAMH 2006 53

14 Colucci E Cultural issues in suicide risk assessment Suicidal BehaviorAssessment of People-at-risk New Delhi SAGEKumar U Mandal MK 2009

15 Colucci E Martin G Ethnocultural aspects of suicide in young people asystematic literature review Part 1 Rates and methods of youth suicideSuicide Life Threat Behav 2007 37197-221

16 Colucci E Martin G Ethnocultural aspects of suicide in young people asystematic literature review Part 2 Risk factors precipitating agentsand attitudes toward suicide Suicide Life Threat Behav 2007 37222-237

17 Hawgood J DeLeo D Suicide Prevention Skills Training Manual AnAccredited Training Program Brisbane Australia Griffith University 2002

18 Mental Health and Drug and Alcohol Office Mental Health for EmergencyDepartments - A Reference Guide Sydney NSW Department of Health2002

19 Colucci E Recognizing spirituality in the assessment and prevention ofsuicidal behaviour WCPRR 2008 377-95 [httpwwwwcprrorgpdf03-022008027795pdf]

20 Hasson F Keeney S McKenna H Research guidelines for the Delphisurvey technique J Adv Nurs 2000 321008-1015

21 SurveyMonkey [httpwwwsurveymonkeycom]22 Hart LM Jorm AF Kanowski LG Kelly CM Langlands RL Mental health first

aid for Indigenous Australians using Delphi consensus studies todevelop guidelines for culturally appropriate responses to mental healthproblems BMC Psychiatry 2009 947

23 Minas H Colucci E Jorm AF Evaluation of Mental Health First Aidtraining with members of the Vietnamese community in MelbourneIJMHS 2009 319

24 Jorm AF Kitchener BA Mugford SK Experiences in applying skills learnedin a Mental Health First Aid training course a qualitative study ofparticipantsrsquo stories BMC Psychiatry 2005 543

25 Kitchener BA Jorm AF Mental health first aid training review ofevaluation studies Australian and New Zealand Journal of Psychiatry 2006406-8

doi1011861752-4458-4-4Cite this article as Colucci et al Mental Health First Aid guidelines forhelping a suicidal person a Delphi consensus study in IndiaInternational Journal of Mental Health Systems 2010 44

Colucci et al International Journal of Mental Health Systems 2010 44httpwwwijmhscomcontent414

Page 8 of 8

Panelist members were asked to rate each statementaccording to how important they believed it was as apotential first aid guideline for helping a suicidal personThe response scale was 1 Essential 2 Important 3Donrsquot knowDepends 4 Unimportant 5 Should not beincluded The scale was purposefully asymmetricbecause only items with positive ratings were of interestfor the guidelines This scale has worked well in pre-vious guideline development work [7]At the end of each block of items the panel members

were asked to give any comments or add any additionalactions that were not included in the questionnaire Thesuggestions made by the panel members in response tothe open-ended questions were reviewed by the researchteam and used to construct new items Suggestions wereaccepted and added to Round 2 if they represented atruly new idea could be interpreted unambiguously andwere actions Suggestions were rejected if they werenear-duplicates of items in the questionnaire if theywere too specific too general or were more appropriateto therapy than first aid This was the place where cul-turally specific material could be introducedResponses were analysed to give the percentage of the

panel who rated an item as either ldquoessentialrdquo or ldquoimpor-tantrdquo Items for which there was at least 80 consensuswere included in the guidelines Items were re-rated if70-79 of the panel rated them as ldquoEssentialrdquo orldquoImportantrdquo A small number of items that receivedmore than 50 of ldquoDonrsquot knowDependsrdquo or ldquoNot surerdquoanswers were reworded to make them clearer and re-rated For example lsquocontact the personrsquos spiritual orreligious leaderrsquo became lsquocontact the personrsquos spiritualor religious leader if they have one lsquoItems that metneither condition were rejectedIn Round 2 a second questionnaire was prepared This

consisted of any new item that was generated from thecomments in Round 1 plus items that were positivelyrated by at least 70 of respondents but did not reachthe 80 criterion for inclusion Participants received anemail with an individualized link to the online survey anda word file that together with the latter items fed back astatistical summary of the items that were to be re-rated(ie their own original response to the item together withtotal percentages of endorsement of the item) They weretold that they did not have to change their responseswhen re-rating an item but that if they wished theywould have the opportunity to do so Panel memberswere asked to re-rate items which approached the desiredlevel of consensus and rate the new culturally specificitems after reading this feedback letter At the end of thisround any item that reached the 80 consensus criterionwas selected for inclusion in the guidelinesIn Round 3 any of the new items generated from the

open-ended questions in Round 1 that did not reach

consensus in Round 2 went back for re-rating (togetherwith a few items which received an excessively highnumber -more than 50- of ldquoDonrsquot knowdependsrdquoanswers) Participants received a statistical summary ofthe results as for Round 2 Again items that reachedthe required level of consensus were included in theguidelines

Cultural appropriateness of guidelinesAs described above the questionnaire on potential firstaid actions that was developed for English-speakingcountries (with a few additionalmodified items) was thestarting point for the Round 1 of the Delphi process forthis project At each round panel members were askedto suggest additional actions that were not covered inthe original questionnaire specifically to include itemsthat were relevant to local cultural circumstancesvalues etc These new items were rated in Rounds 2and 3 Panel members were also invited to comment onitems that were in the initial questionnaire that theyconsidered to be culturally irrelevant or unacceptable orthat would not be feasible because of the local healthsystem and other resources Moreover in the formationof the expert panels in each country we were careful toinclude as wide a representation (cultural and geo-graphic) of professionals as possible

EthicsEthics approval was obtained from the University ofMelbourne Human Research Ethics Committee (ProjectNo HREC 0605537)

ResultsSampleIn India 30 panel members were involved in Round 1(ie 68 of the experts who were invited to participate)25 in Round 2 and 23 in Round 3 All panel memberswere currently working in India The majority were psy-chiatrists (63) and psychologists (27) Two partici-pants were social workers and one was an occupationaltherapist The panel comprised of 17 males and 13females The majority (57) of the participants were inthe age range 40-49 years 3 were aged 18-29 years 6aged 30-39 years and 4 aged 50-59 yearsSome information was also collected on the clinical

experience of the panel members On average partici-pants reported that they had practiced in mental healthpsychiatry for 15 years (the shortest time was 2 yearsand the longest 30 years) Less of a quarter of the parti-cipants (23) received some formal education related totheir profession overseas (mainly in UK and one in Aus-tralia) Slightly over a third of the participants (37)reported having received a formal training specificallyon suicide preventionintervention However when

Colucci et al International Journal of Mental Health Systems 2010 44httpwwwijmhscomcontent414

Page 5 of 8

asked to state how well prepared they felt to assist a sui-cidal person 33 answered ldquoNot at allrdquo 23 ldquosomewhatpreparedrdquo 47 ldquomostly preparedrdquo and 27 ldquovery pre-paredrdquo Although participants generally felt prepared toassist a suicidal person in their opinion most people inIndia are not at all prepared (53) or somewhat pre-pared (43) Only one person believed others are mostlyprepared to assist

Items endorsementAfter three Delphi rounds there were 71 items thatwere rated as ldquoessentialrdquo or ldquoimportantrdquo by 80 or moreof the panel membersAt Round 2 30 new items suggested by participants

were added to the questionnaire The followings areexamples of such itemsbull An important warning sign for suicide is if a person

is saying they wish or intend to see or speak to someonewho is dead (eg a deceased family member)bull An important warning sign for suicide is if a person

is expressing in words or actions a sense of shame(eg from failure or loss)bull The first aider should not offer false hope or make

unrealistic promisesbull The first aider should not dismiss the personrsquos feel-

ings or compare their problems to the problems ofothersbull When talking to the suicidal person the first aider

should use the personrsquos belief systems and values toencourage them to change their mind about suicidebull The first aider should contact the elders in the per-

sonrsquos communityA number of responses to the Round 1 open-ended

questions did not meet criteria for creation of a newitem (eg they did not fit the definition of first aid ordid not suggest a clear action) or were commentssug-gestions The following are examples of the commentsand suggestions that did not generate new itemsbull ldquo The idea of suicide first aid does not exist in our

country It should be strongly encouraged at all levelsespecially in schools as the prevalence of suicide amongschool kids is alarming ()rdquobull ldquo I think that there should be more awareness about

ldquosuiciderdquo in our country so that people are sensitizedabout the ldquowarning signsrdquo of this person even before hecan attempt suicide In my culture since the family issuch an important support system they must beinformed right from the startrdquobull ldquo Psychiatrists psychologists and other mental health

professionals should receive training in how to handlesuicidal individuals victims of attempted suicide andsurvivors of suiciderdquobull ldquoIn our society individual freedom and opinion is

not as important as collective opinion Hence it is not

difficult to dissuade suicide by involving other indivi-duals in the family and society However the motivationof ldquoothersrdquo is not always highrdquobull ldquoIn eastern culture people are less likely to take the

issue seriously when one discloses onersquos intention tocommit suiciderdquoSee the Additional file 1 for a complete list of rated

statements including the percentage of panel membersendorsing each itemAt the end of the survey participants were asked their

opinions about the likely effectiveness of suicide firstaid using a 5-point Likert scale (from ldquodefinitely yesrdquo toldquodefinitely nordquo) All of them believed that if the firstaider does the right thing the risk of suicide can bereduced Substantial proportions of the respondentsthought that if the first aider does the wrong thing therisk of suicide can definitely (27) or probably (45) beincreased (21 answered ldquoDonrsquot knowdependsrdquo and14 ldquoProbably nordquo)The longer-term goal of the project is to use the

guidelines to develop implement and evaluate a trainingprogram on suicide first aid in India When asked ifthey thought members of the public should receive suchtraining 69 of panel members responded ldquodefinitelyyesrdquo and 27 ldquoprobably yesrdquo Only one respondentanswered ldquodonrsquot knowdependsrdquo

Development of statements that constitute the guidelinesThe output from the Delphi process was a set of agreedupon action statements The statements refer to actionsthat can be done by a mental health first aider To beusefully communicated these action statements havebeen woven into an integrated piece of text (instead of alist of ldquodosrdquo and ldquodonrsquotsrdquo) which become the SuicideFirst Aid Guidelines (see Additional File 2)

Participant feedback and modification of draft guidelinesThe draft guidelines were sent to all panel members fortheir comments and final endorsement Since the guide-lines were meant to be useful to members of the publicit was important to ensure that they were written to becomprehensible to the target non-professional reader-ship Feedback from panel members was explicitlysought on the structure and readability of the guidelinesand suggested improvements were incorporated in thefinal version

DiscussionThis project has demonstrated that it is possible toachieve consensus among mental health professionalson first aid strategies for suicidal thoughts and beha-viour and that the Delphi method is suitable for devel-oping consensus guidelines in India The method hasbeen similarly successful in Japan and the Philippines

Colucci et al International Journal of Mental Health Systems 2010 44httpwwwijmhscomcontent414

Page 6 of 8

We would suggest that guideline development studiesusing a similar method could be carried in a number ofother countries As well as developing country specificguidelines it will also be possible to develop guidelinesthat are appropriate for cultural minorities within acountry This approach has been used in Australia witha separate Delphi study undertaken to develop guide-lines for Aboriginal Australians using Aboriginal mentalhealth experts as panel members [22] and specificteaching programs have been developed for non-Englishspeaking immigrant communities [23]The next steps will be dissemination and use of the

guidelines for the purpose of increasing communitymembersrsquo ability to recognize the risk of suicide andundertake basic first aid actions A number of panelmembers in collaboration with our research team arecurrently seeking further funding so that the guidelinescan be translated into local languages and to examinewhether modifications are required for cultural minoritygroups The guidelines that have been developed willserve as a basis for detailed work on culturally appropri-ate guideline development in languages other than Eng-lish and for specific national and sub-national culturalgroupsThese guidelines can be used as a source of advice to

the public as a basis for determining the curriculum offirst aid training courses and as a standard againstwhich to evaluate the quality of existing materials andprograms The guidelines will inform the developmentof culturally appropriate training programs and informa-tion materials for how a member of the public can assistsomeone who is suicidal In some countries and areaswith less developed healthcare systems we believe theguidelines will be useful for primary health workers aswell as for members of the public It is anticipated thatthe results of this project will contribute to a programof training for community nurses and midwives and forvillage mental health workers to enable them to contri-bute more effectively to suicide prevention programs Itwill of course be necessary to rigorously evaluate theimpact of such training programs [23-25]

LimitationsOne limitation of this study is the small number ofpanel members although Delphi studies have been suc-cessfully run even with smaller groupsWe have developed these guidelines for India as a

whole while recognizing that India is characterised byremarkable cultural and linguistic diversity It is possiblethat the guidelines are not applicable to minority cul-tures within IndiaThe questionnaire was administered in English rather

than in the panelistsrsquo native languages This of courselimits the general applicability of the findings It is

possible that there would have been more culturally spe-cific responses if panelists had used their nativelanguageFuture studies should recruit broader and more

representative expert panels including where possibleprofessionals from all the relevant mental health disci-plines and consumer and carer representatives This ispresently difficult in many Asian countries becausethere are very few (if any) clinical psychologists psy-chiatric social workers occupational therapists andmental health nurses and the participation of consu-mers and carers in such research as members of anlsquoexpert panelrsquo rather than as research subjects is stilluncommon [10]Another limitation is that the inclusion of culturally

relevant material was dependent on panelists respondingto the open-ended questions and not every participantdid this This may have been in some cases due to lackof time or because the participants in this study werebetter able to read English than to write it It may alsobe because in questionnaires of all kinds that requireratings to be made respondents rarely take the opportu-nity to write comments or to make suggestions whenthe opportunity is given [10] However it must be notedthat compared to other similar mental health first aidguideline research a considerable number of suggestionsfor new items were given This might have been becauseof the emphasis in the instructions to participants onproviding suggestions based on participantsrsquo culturalsocial and religious settings in each section of thequestionnaire

ConclusionsThere is a growing awareness of suicide as a major pub-lic health problem even though there is a taboo inmany societies against discussing it openly [1] Develop-ing suicide first aid guidelines for community membersand training programs based on these might also con-tribute towards changing societyrsquos attitudes towards sui-cide and people who consider suicideThis study has demonstrated that it is possible to

reach consensus for the development of guidelines forIndia Although the guidelines were designed for thepublic they may also contain advice that might be help-ful to people working in health and welfare professionsWhere the guidelines are used as the basis for first aid

training efforts need to be made as far as possible toevaluate their impact on the first aiderrsquos helping beha-viour and on the recipients of the first aid This willassist researchers to develop an evidence base for mentalhealth first aid and suicide prevention initiativesIn a WHO news release [2] it was stated that ldquoItrsquos

important to realise that suicide is preventablerdquo By col-laborating with local experts to agree on a minimum set

Colucci et al International Journal of Mental Health Systems 2010 44httpwwwijmhscomcontent414

Page 7 of 8

of suicide first aid actions and by making such guide-lines freely and easily accessible to everyone we hope toconvey the message that suicide is preventable suicideis everyonersquos business and everyone can contribute toits reduction Members of the general public have a cru-cial role to play in suicide prevention Creating opportu-nities for the public to learn basic first aid actions andhow to implement them when needed is an importantstep towards more effective suicide prevention

Additional file 1 Table of data showing the items included in theDelphi survey and the endorsement levels from the Indian panelmembersClick here for file[ httpwwwbiomedcentralcomcontentsupplementary1752-4458-4-4-S1DOC ]

Additional file 2 First aid guidelines for India This file may bedistributed freely with the authorship and copyright details intact Pleasedo not alter the text or remove the authorship and copyright detailsClick here for file[ httpwwwbiomedcentralcomcontentsupplementary1752-4458-4-4-S2PDF ]

AcknowledgementsThe authors gratefully acknowledge the time effort and contribution of thefollowing panel members Pratheesh Kumar Sanjeev Jain Bernadette PereiraAchira Chatterjee Ramamurti Mangala Jai Ranjan Ram Mathew VargheseNeerja Choudhary Ankita Khanna Vikram Patel Alok Bajpai Abdul BariRakesh Lall Kavita Arora Gracy Andrews Lata Jacob Nishi Misra PadmavatiRamachandran Melvin Chagas Silva Subir Hajra Choudhary Updesh KumarSudipto Chatterjee Alok Sarin Rangaswamy Thara Prathama GuhaChaudhuri Sujit John Anil Rane Aniruddha Deb Santanu Goswami VivekBenegalFunding for the project was provided by the American Foundation forSuicide Prevention the Centre for International Mental Health (The Universityof Melbourne) Jorm and Kelly are supported by grants from the NationalHealth and Medical Research Council of Australia

Author details1Centre for International Mental Health Melbourne School of PopulationHealth The University of Melbourne Parkville Victoria 3010 Australia2Mental Health First Aid Training and Research Program ORYGEN YouthHealth Research Centre The University of Melbourne Parkville Victoria 3052Australia 3Sangath Centre 8411 Alto-Porvorim Goa 403521 India

Authorsrsquo contributionsEC recruited clinical experts revised the existing questionnaire prepared andadministered the on-line surveys for all three rounds analysed the dataprepared the draft and final guidelines and wrote the first draft of themanuscript CMK wrote the former questionnaire and contributed to therevised version supervised every stage of the project and co-wrote theguidelines HM co-wrote the grant application recruited the main localcollaborators and clinical experts reviewed the Round 1 questionnaire andthe guidelines AFJ co-wrote the grant application and developed themethod SC was the main local collaborator in the study and recruited themajority of the clinical experts All authors contributed to the writing of themanuscript and approved the final version

Competing interestsThe authors declare that they have no competing interests

Received 16 November 2009 Accepted 19 February 2010Published 19 February 2010

References1 WHO World Suicide Prevention Day [httpwwwwhointmediacentre

newsstatements2007s16en]2 WHO Suicide huge but preventable public health problem [httpwww

whointmediacentrenewsreleases2004pr61en]3 Tierney RJ Suicide intervention training evaluation a preliminary report

Crisis 1994 1569-764 Kitchener BA Jorm AF Mental health first aid training for the public

evaluation of effects on knowledge attitudes and helping behavior BMCPsychiatry 2002 210

5 Linstone HA Turoff M The Delphi method techniques and applications2002 [httpisnjitedupubsdelphibook]

6 Snyder-Halpern R Thompson CB Schaffer J Comparison of mailed vsInternet applications of the Delphi technique in clinical informaticsresearch Proc AMIA Symp 2000 809-813

7 Kelly CM Jorm AF Kitchener BA Langlands RL Development of mentalhealth first aid guidelines for suicidal ideation and behaviour a Delphistudy BMC Psychiatry 2008 817

8 Kelly CM Jorm AF Kitchener BA Langlands RL Development of mentalhealth first aid guidelines for deliberate non-suicidal self-injury a Delphistudy BMC Psychiatry 2008 862

9 Kelly CM Jorm AF Kitchener BA Development of mental health first aidguidelines for panic attacks a Delphi study BMC Psychiatry 2009 949

10 Jorm AF Minas H Langlands RL Kelly ML First aid guidelines forpsychosis in Asian countries A Delphi consensus study Int J Ment HealthSyst 2008 22

11 Langlands RL Jorm AF Kelly CM Kitchener BA First aid for depression aDelphi consensus study with consumers carers and clinicians J AffectDisord 2008 105157-165

12 Hart LM Jorm AF Paxton SJ Kelly CM Kitchener BA First Aid for EatingDisorders Eating Disorders 2009 17357-384

13 Colucci E The cultural facet of suicidal behaviour Its importance andneglect AeJAMH 2006 53

14 Colucci E Cultural issues in suicide risk assessment Suicidal BehaviorAssessment of People-at-risk New Delhi SAGEKumar U Mandal MK 2009

15 Colucci E Martin G Ethnocultural aspects of suicide in young people asystematic literature review Part 1 Rates and methods of youth suicideSuicide Life Threat Behav 2007 37197-221

16 Colucci E Martin G Ethnocultural aspects of suicide in young people asystematic literature review Part 2 Risk factors precipitating agentsand attitudes toward suicide Suicide Life Threat Behav 2007 37222-237

17 Hawgood J DeLeo D Suicide Prevention Skills Training Manual AnAccredited Training Program Brisbane Australia Griffith University 2002

18 Mental Health and Drug and Alcohol Office Mental Health for EmergencyDepartments - A Reference Guide Sydney NSW Department of Health2002

19 Colucci E Recognizing spirituality in the assessment and prevention ofsuicidal behaviour WCPRR 2008 377-95 [httpwwwwcprrorgpdf03-022008027795pdf]

20 Hasson F Keeney S McKenna H Research guidelines for the Delphisurvey technique J Adv Nurs 2000 321008-1015

21 SurveyMonkey [httpwwwsurveymonkeycom]22 Hart LM Jorm AF Kanowski LG Kelly CM Langlands RL Mental health first

aid for Indigenous Australians using Delphi consensus studies todevelop guidelines for culturally appropriate responses to mental healthproblems BMC Psychiatry 2009 947

23 Minas H Colucci E Jorm AF Evaluation of Mental Health First Aidtraining with members of the Vietnamese community in MelbourneIJMHS 2009 319

24 Jorm AF Kitchener BA Mugford SK Experiences in applying skills learnedin a Mental Health First Aid training course a qualitative study ofparticipantsrsquo stories BMC Psychiatry 2005 543

25 Kitchener BA Jorm AF Mental health first aid training review ofevaluation studies Australian and New Zealand Journal of Psychiatry 2006406-8

doi1011861752-4458-4-4Cite this article as Colucci et al Mental Health First Aid guidelines forhelping a suicidal person a Delphi consensus study in IndiaInternational Journal of Mental Health Systems 2010 44

Colucci et al International Journal of Mental Health Systems 2010 44httpwwwijmhscomcontent414

Page 8 of 8

asked to state how well prepared they felt to assist a sui-cidal person 33 answered ldquoNot at allrdquo 23 ldquosomewhatpreparedrdquo 47 ldquomostly preparedrdquo and 27 ldquovery pre-paredrdquo Although participants generally felt prepared toassist a suicidal person in their opinion most people inIndia are not at all prepared (53) or somewhat pre-pared (43) Only one person believed others are mostlyprepared to assist

Items endorsementAfter three Delphi rounds there were 71 items thatwere rated as ldquoessentialrdquo or ldquoimportantrdquo by 80 or moreof the panel membersAt Round 2 30 new items suggested by participants

were added to the questionnaire The followings areexamples of such itemsbull An important warning sign for suicide is if a person

is saying they wish or intend to see or speak to someonewho is dead (eg a deceased family member)bull An important warning sign for suicide is if a person

is expressing in words or actions a sense of shame(eg from failure or loss)bull The first aider should not offer false hope or make

unrealistic promisesbull The first aider should not dismiss the personrsquos feel-

ings or compare their problems to the problems ofothersbull When talking to the suicidal person the first aider

should use the personrsquos belief systems and values toencourage them to change their mind about suicidebull The first aider should contact the elders in the per-

sonrsquos communityA number of responses to the Round 1 open-ended

questions did not meet criteria for creation of a newitem (eg they did not fit the definition of first aid ordid not suggest a clear action) or were commentssug-gestions The following are examples of the commentsand suggestions that did not generate new itemsbull ldquo The idea of suicide first aid does not exist in our

country It should be strongly encouraged at all levelsespecially in schools as the prevalence of suicide amongschool kids is alarming ()rdquobull ldquo I think that there should be more awareness about

ldquosuiciderdquo in our country so that people are sensitizedabout the ldquowarning signsrdquo of this person even before hecan attempt suicide In my culture since the family issuch an important support system they must beinformed right from the startrdquobull ldquo Psychiatrists psychologists and other mental health

professionals should receive training in how to handlesuicidal individuals victims of attempted suicide andsurvivors of suiciderdquobull ldquoIn our society individual freedom and opinion is

not as important as collective opinion Hence it is not

difficult to dissuade suicide by involving other indivi-duals in the family and society However the motivationof ldquoothersrdquo is not always highrdquobull ldquoIn eastern culture people are less likely to take the

issue seriously when one discloses onersquos intention tocommit suiciderdquoSee the Additional file 1 for a complete list of rated

statements including the percentage of panel membersendorsing each itemAt the end of the survey participants were asked their

opinions about the likely effectiveness of suicide firstaid using a 5-point Likert scale (from ldquodefinitely yesrdquo toldquodefinitely nordquo) All of them believed that if the firstaider does the right thing the risk of suicide can bereduced Substantial proportions of the respondentsthought that if the first aider does the wrong thing therisk of suicide can definitely (27) or probably (45) beincreased (21 answered ldquoDonrsquot knowdependsrdquo and14 ldquoProbably nordquo)The longer-term goal of the project is to use the

guidelines to develop implement and evaluate a trainingprogram on suicide first aid in India When asked ifthey thought members of the public should receive suchtraining 69 of panel members responded ldquodefinitelyyesrdquo and 27 ldquoprobably yesrdquo Only one respondentanswered ldquodonrsquot knowdependsrdquo

Development of statements that constitute the guidelinesThe output from the Delphi process was a set of agreedupon action statements The statements refer to actionsthat can be done by a mental health first aider To beusefully communicated these action statements havebeen woven into an integrated piece of text (instead of alist of ldquodosrdquo and ldquodonrsquotsrdquo) which become the SuicideFirst Aid Guidelines (see Additional File 2)

Participant feedback and modification of draft guidelinesThe draft guidelines were sent to all panel members fortheir comments and final endorsement Since the guide-lines were meant to be useful to members of the publicit was important to ensure that they were written to becomprehensible to the target non-professional reader-ship Feedback from panel members was explicitlysought on the structure and readability of the guidelinesand suggested improvements were incorporated in thefinal version

DiscussionThis project has demonstrated that it is possible toachieve consensus among mental health professionalson first aid strategies for suicidal thoughts and beha-viour and that the Delphi method is suitable for devel-oping consensus guidelines in India The method hasbeen similarly successful in Japan and the Philippines

Colucci et al International Journal of Mental Health Systems 2010 44httpwwwijmhscomcontent414

Page 6 of 8

We would suggest that guideline development studiesusing a similar method could be carried in a number ofother countries As well as developing country specificguidelines it will also be possible to develop guidelinesthat are appropriate for cultural minorities within acountry This approach has been used in Australia witha separate Delphi study undertaken to develop guide-lines for Aboriginal Australians using Aboriginal mentalhealth experts as panel members [22] and specificteaching programs have been developed for non-Englishspeaking immigrant communities [23]The next steps will be dissemination and use of the

guidelines for the purpose of increasing communitymembersrsquo ability to recognize the risk of suicide andundertake basic first aid actions A number of panelmembers in collaboration with our research team arecurrently seeking further funding so that the guidelinescan be translated into local languages and to examinewhether modifications are required for cultural minoritygroups The guidelines that have been developed willserve as a basis for detailed work on culturally appropri-ate guideline development in languages other than Eng-lish and for specific national and sub-national culturalgroupsThese guidelines can be used as a source of advice to

the public as a basis for determining the curriculum offirst aid training courses and as a standard againstwhich to evaluate the quality of existing materials andprograms The guidelines will inform the developmentof culturally appropriate training programs and informa-tion materials for how a member of the public can assistsomeone who is suicidal In some countries and areaswith less developed healthcare systems we believe theguidelines will be useful for primary health workers aswell as for members of the public It is anticipated thatthe results of this project will contribute to a programof training for community nurses and midwives and forvillage mental health workers to enable them to contri-bute more effectively to suicide prevention programs Itwill of course be necessary to rigorously evaluate theimpact of such training programs [23-25]

LimitationsOne limitation of this study is the small number ofpanel members although Delphi studies have been suc-cessfully run even with smaller groupsWe have developed these guidelines for India as a

whole while recognizing that India is characterised byremarkable cultural and linguistic diversity It is possiblethat the guidelines are not applicable to minority cul-tures within IndiaThe questionnaire was administered in English rather

than in the panelistsrsquo native languages This of courselimits the general applicability of the findings It is

possible that there would have been more culturally spe-cific responses if panelists had used their nativelanguageFuture studies should recruit broader and more

representative expert panels including where possibleprofessionals from all the relevant mental health disci-plines and consumer and carer representatives This ispresently difficult in many Asian countries becausethere are very few (if any) clinical psychologists psy-chiatric social workers occupational therapists andmental health nurses and the participation of consu-mers and carers in such research as members of anlsquoexpert panelrsquo rather than as research subjects is stilluncommon [10]Another limitation is that the inclusion of culturally

relevant material was dependent on panelists respondingto the open-ended questions and not every participantdid this This may have been in some cases due to lackof time or because the participants in this study werebetter able to read English than to write it It may alsobe because in questionnaires of all kinds that requireratings to be made respondents rarely take the opportu-nity to write comments or to make suggestions whenthe opportunity is given [10] However it must be notedthat compared to other similar mental health first aidguideline research a considerable number of suggestionsfor new items were given This might have been becauseof the emphasis in the instructions to participants onproviding suggestions based on participantsrsquo culturalsocial and religious settings in each section of thequestionnaire

ConclusionsThere is a growing awareness of suicide as a major pub-lic health problem even though there is a taboo inmany societies against discussing it openly [1] Develop-ing suicide first aid guidelines for community membersand training programs based on these might also con-tribute towards changing societyrsquos attitudes towards sui-cide and people who consider suicideThis study has demonstrated that it is possible to

reach consensus for the development of guidelines forIndia Although the guidelines were designed for thepublic they may also contain advice that might be help-ful to people working in health and welfare professionsWhere the guidelines are used as the basis for first aid

training efforts need to be made as far as possible toevaluate their impact on the first aiderrsquos helping beha-viour and on the recipients of the first aid This willassist researchers to develop an evidence base for mentalhealth first aid and suicide prevention initiativesIn a WHO news release [2] it was stated that ldquoItrsquos

important to realise that suicide is preventablerdquo By col-laborating with local experts to agree on a minimum set

Colucci et al International Journal of Mental Health Systems 2010 44httpwwwijmhscomcontent414

Page 7 of 8

of suicide first aid actions and by making such guide-lines freely and easily accessible to everyone we hope toconvey the message that suicide is preventable suicideis everyonersquos business and everyone can contribute toits reduction Members of the general public have a cru-cial role to play in suicide prevention Creating opportu-nities for the public to learn basic first aid actions andhow to implement them when needed is an importantstep towards more effective suicide prevention

Additional file 1 Table of data showing the items included in theDelphi survey and the endorsement levels from the Indian panelmembersClick here for file[ httpwwwbiomedcentralcomcontentsupplementary1752-4458-4-4-S1DOC ]

Additional file 2 First aid guidelines for India This file may bedistributed freely with the authorship and copyright details intact Pleasedo not alter the text or remove the authorship and copyright detailsClick here for file[ httpwwwbiomedcentralcomcontentsupplementary1752-4458-4-4-S2PDF ]

AcknowledgementsThe authors gratefully acknowledge the time effort and contribution of thefollowing panel members Pratheesh Kumar Sanjeev Jain Bernadette PereiraAchira Chatterjee Ramamurti Mangala Jai Ranjan Ram Mathew VargheseNeerja Choudhary Ankita Khanna Vikram Patel Alok Bajpai Abdul BariRakesh Lall Kavita Arora Gracy Andrews Lata Jacob Nishi Misra PadmavatiRamachandran Melvin Chagas Silva Subir Hajra Choudhary Updesh KumarSudipto Chatterjee Alok Sarin Rangaswamy Thara Prathama GuhaChaudhuri Sujit John Anil Rane Aniruddha Deb Santanu Goswami VivekBenegalFunding for the project was provided by the American Foundation forSuicide Prevention the Centre for International Mental Health (The Universityof Melbourne) Jorm and Kelly are supported by grants from the NationalHealth and Medical Research Council of Australia

Author details1Centre for International Mental Health Melbourne School of PopulationHealth The University of Melbourne Parkville Victoria 3010 Australia2Mental Health First Aid Training and Research Program ORYGEN YouthHealth Research Centre The University of Melbourne Parkville Victoria 3052Australia 3Sangath Centre 8411 Alto-Porvorim Goa 403521 India

Authorsrsquo contributionsEC recruited clinical experts revised the existing questionnaire prepared andadministered the on-line surveys for all three rounds analysed the dataprepared the draft and final guidelines and wrote the first draft of themanuscript CMK wrote the former questionnaire and contributed to therevised version supervised every stage of the project and co-wrote theguidelines HM co-wrote the grant application recruited the main localcollaborators and clinical experts reviewed the Round 1 questionnaire andthe guidelines AFJ co-wrote the grant application and developed themethod SC was the main local collaborator in the study and recruited themajority of the clinical experts All authors contributed to the writing of themanuscript and approved the final version

Competing interestsThe authors declare that they have no competing interests

Received 16 November 2009 Accepted 19 February 2010Published 19 February 2010

References1 WHO World Suicide Prevention Day [httpwwwwhointmediacentre

newsstatements2007s16en]2 WHO Suicide huge but preventable public health problem [httpwww

whointmediacentrenewsreleases2004pr61en]3 Tierney RJ Suicide intervention training evaluation a preliminary report

Crisis 1994 1569-764 Kitchener BA Jorm AF Mental health first aid training for the public

evaluation of effects on knowledge attitudes and helping behavior BMCPsychiatry 2002 210

5 Linstone HA Turoff M The Delphi method techniques and applications2002 [httpisnjitedupubsdelphibook]

6 Snyder-Halpern R Thompson CB Schaffer J Comparison of mailed vsInternet applications of the Delphi technique in clinical informaticsresearch Proc AMIA Symp 2000 809-813

7 Kelly CM Jorm AF Kitchener BA Langlands RL Development of mentalhealth first aid guidelines for suicidal ideation and behaviour a Delphistudy BMC Psychiatry 2008 817

8 Kelly CM Jorm AF Kitchener BA Langlands RL Development of mentalhealth first aid guidelines for deliberate non-suicidal self-injury a Delphistudy BMC Psychiatry 2008 862

9 Kelly CM Jorm AF Kitchener BA Development of mental health first aidguidelines for panic attacks a Delphi study BMC Psychiatry 2009 949

10 Jorm AF Minas H Langlands RL Kelly ML First aid guidelines forpsychosis in Asian countries A Delphi consensus study Int J Ment HealthSyst 2008 22

11 Langlands RL Jorm AF Kelly CM Kitchener BA First aid for depression aDelphi consensus study with consumers carers and clinicians J AffectDisord 2008 105157-165

12 Hart LM Jorm AF Paxton SJ Kelly CM Kitchener BA First Aid for EatingDisorders Eating Disorders 2009 17357-384

13 Colucci E The cultural facet of suicidal behaviour Its importance andneglect AeJAMH 2006 53

14 Colucci E Cultural issues in suicide risk assessment Suicidal BehaviorAssessment of People-at-risk New Delhi SAGEKumar U Mandal MK 2009

15 Colucci E Martin G Ethnocultural aspects of suicide in young people asystematic literature review Part 1 Rates and methods of youth suicideSuicide Life Threat Behav 2007 37197-221

16 Colucci E Martin G Ethnocultural aspects of suicide in young people asystematic literature review Part 2 Risk factors precipitating agentsand attitudes toward suicide Suicide Life Threat Behav 2007 37222-237

17 Hawgood J DeLeo D Suicide Prevention Skills Training Manual AnAccredited Training Program Brisbane Australia Griffith University 2002

18 Mental Health and Drug and Alcohol Office Mental Health for EmergencyDepartments - A Reference Guide Sydney NSW Department of Health2002

19 Colucci E Recognizing spirituality in the assessment and prevention ofsuicidal behaviour WCPRR 2008 377-95 [httpwwwwcprrorgpdf03-022008027795pdf]

20 Hasson F Keeney S McKenna H Research guidelines for the Delphisurvey technique J Adv Nurs 2000 321008-1015

21 SurveyMonkey [httpwwwsurveymonkeycom]22 Hart LM Jorm AF Kanowski LG Kelly CM Langlands RL Mental health first

aid for Indigenous Australians using Delphi consensus studies todevelop guidelines for culturally appropriate responses to mental healthproblems BMC Psychiatry 2009 947

23 Minas H Colucci E Jorm AF Evaluation of Mental Health First Aidtraining with members of the Vietnamese community in MelbourneIJMHS 2009 319

24 Jorm AF Kitchener BA Mugford SK Experiences in applying skills learnedin a Mental Health First Aid training course a qualitative study ofparticipantsrsquo stories BMC Psychiatry 2005 543

25 Kitchener BA Jorm AF Mental health first aid training review ofevaluation studies Australian and New Zealand Journal of Psychiatry 2006406-8

doi1011861752-4458-4-4Cite this article as Colucci et al Mental Health First Aid guidelines forhelping a suicidal person a Delphi consensus study in IndiaInternational Journal of Mental Health Systems 2010 44

Colucci et al International Journal of Mental Health Systems 2010 44httpwwwijmhscomcontent414

Page 8 of 8

We would suggest that guideline development studiesusing a similar method could be carried in a number ofother countries As well as developing country specificguidelines it will also be possible to develop guidelinesthat are appropriate for cultural minorities within acountry This approach has been used in Australia witha separate Delphi study undertaken to develop guide-lines for Aboriginal Australians using Aboriginal mentalhealth experts as panel members [22] and specificteaching programs have been developed for non-Englishspeaking immigrant communities [23]The next steps will be dissemination and use of the

guidelines for the purpose of increasing communitymembersrsquo ability to recognize the risk of suicide andundertake basic first aid actions A number of panelmembers in collaboration with our research team arecurrently seeking further funding so that the guidelinescan be translated into local languages and to examinewhether modifications are required for cultural minoritygroups The guidelines that have been developed willserve as a basis for detailed work on culturally appropri-ate guideline development in languages other than Eng-lish and for specific national and sub-national culturalgroupsThese guidelines can be used as a source of advice to

the public as a basis for determining the curriculum offirst aid training courses and as a standard againstwhich to evaluate the quality of existing materials andprograms The guidelines will inform the developmentof culturally appropriate training programs and informa-tion materials for how a member of the public can assistsomeone who is suicidal In some countries and areaswith less developed healthcare systems we believe theguidelines will be useful for primary health workers aswell as for members of the public It is anticipated thatthe results of this project will contribute to a programof training for community nurses and midwives and forvillage mental health workers to enable them to contri-bute more effectively to suicide prevention programs Itwill of course be necessary to rigorously evaluate theimpact of such training programs [23-25]

LimitationsOne limitation of this study is the small number ofpanel members although Delphi studies have been suc-cessfully run even with smaller groupsWe have developed these guidelines for India as a

whole while recognizing that India is characterised byremarkable cultural and linguistic diversity It is possiblethat the guidelines are not applicable to minority cul-tures within IndiaThe questionnaire was administered in English rather

than in the panelistsrsquo native languages This of courselimits the general applicability of the findings It is

possible that there would have been more culturally spe-cific responses if panelists had used their nativelanguageFuture studies should recruit broader and more

representative expert panels including where possibleprofessionals from all the relevant mental health disci-plines and consumer and carer representatives This ispresently difficult in many Asian countries becausethere are very few (if any) clinical psychologists psy-chiatric social workers occupational therapists andmental health nurses and the participation of consu-mers and carers in such research as members of anlsquoexpert panelrsquo rather than as research subjects is stilluncommon [10]Another limitation is that the inclusion of culturally

relevant material was dependent on panelists respondingto the open-ended questions and not every participantdid this This may have been in some cases due to lackof time or because the participants in this study werebetter able to read English than to write it It may alsobe because in questionnaires of all kinds that requireratings to be made respondents rarely take the opportu-nity to write comments or to make suggestions whenthe opportunity is given [10] However it must be notedthat compared to other similar mental health first aidguideline research a considerable number of suggestionsfor new items were given This might have been becauseof the emphasis in the instructions to participants onproviding suggestions based on participantsrsquo culturalsocial and religious settings in each section of thequestionnaire

ConclusionsThere is a growing awareness of suicide as a major pub-lic health problem even though there is a taboo inmany societies against discussing it openly [1] Develop-ing suicide first aid guidelines for community membersand training programs based on these might also con-tribute towards changing societyrsquos attitudes towards sui-cide and people who consider suicideThis study has demonstrated that it is possible to

reach consensus for the development of guidelines forIndia Although the guidelines were designed for thepublic they may also contain advice that might be help-ful to people working in health and welfare professionsWhere the guidelines are used as the basis for first aid

training efforts need to be made as far as possible toevaluate their impact on the first aiderrsquos helping beha-viour and on the recipients of the first aid This willassist researchers to develop an evidence base for mentalhealth first aid and suicide prevention initiativesIn a WHO news release [2] it was stated that ldquoItrsquos

important to realise that suicide is preventablerdquo By col-laborating with local experts to agree on a minimum set

Colucci et al International Journal of Mental Health Systems 2010 44httpwwwijmhscomcontent414

Page 7 of 8

of suicide first aid actions and by making such guide-lines freely and easily accessible to everyone we hope toconvey the message that suicide is preventable suicideis everyonersquos business and everyone can contribute toits reduction Members of the general public have a cru-cial role to play in suicide prevention Creating opportu-nities for the public to learn basic first aid actions andhow to implement them when needed is an importantstep towards more effective suicide prevention

Additional file 1 Table of data showing the items included in theDelphi survey and the endorsement levels from the Indian panelmembersClick here for file[ httpwwwbiomedcentralcomcontentsupplementary1752-4458-4-4-S1DOC ]

Additional file 2 First aid guidelines for India This file may bedistributed freely with the authorship and copyright details intact Pleasedo not alter the text or remove the authorship and copyright detailsClick here for file[ httpwwwbiomedcentralcomcontentsupplementary1752-4458-4-4-S2PDF ]

AcknowledgementsThe authors gratefully acknowledge the time effort and contribution of thefollowing panel members Pratheesh Kumar Sanjeev Jain Bernadette PereiraAchira Chatterjee Ramamurti Mangala Jai Ranjan Ram Mathew VargheseNeerja Choudhary Ankita Khanna Vikram Patel Alok Bajpai Abdul BariRakesh Lall Kavita Arora Gracy Andrews Lata Jacob Nishi Misra PadmavatiRamachandran Melvin Chagas Silva Subir Hajra Choudhary Updesh KumarSudipto Chatterjee Alok Sarin Rangaswamy Thara Prathama GuhaChaudhuri Sujit John Anil Rane Aniruddha Deb Santanu Goswami VivekBenegalFunding for the project was provided by the American Foundation forSuicide Prevention the Centre for International Mental Health (The Universityof Melbourne) Jorm and Kelly are supported by grants from the NationalHealth and Medical Research Council of Australia

Author details1Centre for International Mental Health Melbourne School of PopulationHealth The University of Melbourne Parkville Victoria 3010 Australia2Mental Health First Aid Training and Research Program ORYGEN YouthHealth Research Centre The University of Melbourne Parkville Victoria 3052Australia 3Sangath Centre 8411 Alto-Porvorim Goa 403521 India

Authorsrsquo contributionsEC recruited clinical experts revised the existing questionnaire prepared andadministered the on-line surveys for all three rounds analysed the dataprepared the draft and final guidelines and wrote the first draft of themanuscript CMK wrote the former questionnaire and contributed to therevised version supervised every stage of the project and co-wrote theguidelines HM co-wrote the grant application recruited the main localcollaborators and clinical experts reviewed the Round 1 questionnaire andthe guidelines AFJ co-wrote the grant application and developed themethod SC was the main local collaborator in the study and recruited themajority of the clinical experts All authors contributed to the writing of themanuscript and approved the final version

Competing interestsThe authors declare that they have no competing interests

Received 16 November 2009 Accepted 19 February 2010Published 19 February 2010

References1 WHO World Suicide Prevention Day [httpwwwwhointmediacentre

newsstatements2007s16en]2 WHO Suicide huge but preventable public health problem [httpwww

whointmediacentrenewsreleases2004pr61en]3 Tierney RJ Suicide intervention training evaluation a preliminary report

Crisis 1994 1569-764 Kitchener BA Jorm AF Mental health first aid training for the public

evaluation of effects on knowledge attitudes and helping behavior BMCPsychiatry 2002 210

5 Linstone HA Turoff M The Delphi method techniques and applications2002 [httpisnjitedupubsdelphibook]

6 Snyder-Halpern R Thompson CB Schaffer J Comparison of mailed vsInternet applications of the Delphi technique in clinical informaticsresearch Proc AMIA Symp 2000 809-813

7 Kelly CM Jorm AF Kitchener BA Langlands RL Development of mentalhealth first aid guidelines for suicidal ideation and behaviour a Delphistudy BMC Psychiatry 2008 817

8 Kelly CM Jorm AF Kitchener BA Langlands RL Development of mentalhealth first aid guidelines for deliberate non-suicidal self-injury a Delphistudy BMC Psychiatry 2008 862

9 Kelly CM Jorm AF Kitchener BA Development of mental health first aidguidelines for panic attacks a Delphi study BMC Psychiatry 2009 949

10 Jorm AF Minas H Langlands RL Kelly ML First aid guidelines forpsychosis in Asian countries A Delphi consensus study Int J Ment HealthSyst 2008 22

11 Langlands RL Jorm AF Kelly CM Kitchener BA First aid for depression aDelphi consensus study with consumers carers and clinicians J AffectDisord 2008 105157-165

12 Hart LM Jorm AF Paxton SJ Kelly CM Kitchener BA First Aid for EatingDisorders Eating Disorders 2009 17357-384

13 Colucci E The cultural facet of suicidal behaviour Its importance andneglect AeJAMH 2006 53

14 Colucci E Cultural issues in suicide risk assessment Suicidal BehaviorAssessment of People-at-risk New Delhi SAGEKumar U Mandal MK 2009

15 Colucci E Martin G Ethnocultural aspects of suicide in young people asystematic literature review Part 1 Rates and methods of youth suicideSuicide Life Threat Behav 2007 37197-221

16 Colucci E Martin G Ethnocultural aspects of suicide in young people asystematic literature review Part 2 Risk factors precipitating agentsand attitudes toward suicide Suicide Life Threat Behav 2007 37222-237

17 Hawgood J DeLeo D Suicide Prevention Skills Training Manual AnAccredited Training Program Brisbane Australia Griffith University 2002

18 Mental Health and Drug and Alcohol Office Mental Health for EmergencyDepartments - A Reference Guide Sydney NSW Department of Health2002

19 Colucci E Recognizing spirituality in the assessment and prevention ofsuicidal behaviour WCPRR 2008 377-95 [httpwwwwcprrorgpdf03-022008027795pdf]

20 Hasson F Keeney S McKenna H Research guidelines for the Delphisurvey technique J Adv Nurs 2000 321008-1015

21 SurveyMonkey [httpwwwsurveymonkeycom]22 Hart LM Jorm AF Kanowski LG Kelly CM Langlands RL Mental health first

aid for Indigenous Australians using Delphi consensus studies todevelop guidelines for culturally appropriate responses to mental healthproblems BMC Psychiatry 2009 947

23 Minas H Colucci E Jorm AF Evaluation of Mental Health First Aidtraining with members of the Vietnamese community in MelbourneIJMHS 2009 319

24 Jorm AF Kitchener BA Mugford SK Experiences in applying skills learnedin a Mental Health First Aid training course a qualitative study ofparticipantsrsquo stories BMC Psychiatry 2005 543

25 Kitchener BA Jorm AF Mental health first aid training review ofevaluation studies Australian and New Zealand Journal of Psychiatry 2006406-8

doi1011861752-4458-4-4Cite this article as Colucci et al Mental Health First Aid guidelines forhelping a suicidal person a Delphi consensus study in IndiaInternational Journal of Mental Health Systems 2010 44

Colucci et al International Journal of Mental Health Systems 2010 44httpwwwijmhscomcontent414

Page 8 of 8

of suicide first aid actions and by making such guide-lines freely and easily accessible to everyone we hope toconvey the message that suicide is preventable suicideis everyonersquos business and everyone can contribute toits reduction Members of the general public have a cru-cial role to play in suicide prevention Creating opportu-nities for the public to learn basic first aid actions andhow to implement them when needed is an importantstep towards more effective suicide prevention

Additional file 1 Table of data showing the items included in theDelphi survey and the endorsement levels from the Indian panelmembersClick here for file[ httpwwwbiomedcentralcomcontentsupplementary1752-4458-4-4-S1DOC ]

Additional file 2 First aid guidelines for India This file may bedistributed freely with the authorship and copyright details intact Pleasedo not alter the text or remove the authorship and copyright detailsClick here for file[ httpwwwbiomedcentralcomcontentsupplementary1752-4458-4-4-S2PDF ]

AcknowledgementsThe authors gratefully acknowledge the time effort and contribution of thefollowing panel members Pratheesh Kumar Sanjeev Jain Bernadette PereiraAchira Chatterjee Ramamurti Mangala Jai Ranjan Ram Mathew VargheseNeerja Choudhary Ankita Khanna Vikram Patel Alok Bajpai Abdul BariRakesh Lall Kavita Arora Gracy Andrews Lata Jacob Nishi Misra PadmavatiRamachandran Melvin Chagas Silva Subir Hajra Choudhary Updesh KumarSudipto Chatterjee Alok Sarin Rangaswamy Thara Prathama GuhaChaudhuri Sujit John Anil Rane Aniruddha Deb Santanu Goswami VivekBenegalFunding for the project was provided by the American Foundation forSuicide Prevention the Centre for International Mental Health (The Universityof Melbourne) Jorm and Kelly are supported by grants from the NationalHealth and Medical Research Council of Australia

Author details1Centre for International Mental Health Melbourne School of PopulationHealth The University of Melbourne Parkville Victoria 3010 Australia2Mental Health First Aid Training and Research Program ORYGEN YouthHealth Research Centre The University of Melbourne Parkville Victoria 3052Australia 3Sangath Centre 8411 Alto-Porvorim Goa 403521 India

Authorsrsquo contributionsEC recruited clinical experts revised the existing questionnaire prepared andadministered the on-line surveys for all three rounds analysed the dataprepared the draft and final guidelines and wrote the first draft of themanuscript CMK wrote the former questionnaire and contributed to therevised version supervised every stage of the project and co-wrote theguidelines HM co-wrote the grant application recruited the main localcollaborators and clinical experts reviewed the Round 1 questionnaire andthe guidelines AFJ co-wrote the grant application and developed themethod SC was the main local collaborator in the study and recruited themajority of the clinical experts All authors contributed to the writing of themanuscript and approved the final version

Competing interestsThe authors declare that they have no competing interests

Received 16 November 2009 Accepted 19 February 2010Published 19 February 2010

References1 WHO World Suicide Prevention Day [httpwwwwhointmediacentre

newsstatements2007s16en]2 WHO Suicide huge but preventable public health problem [httpwww

whointmediacentrenewsreleases2004pr61en]3 Tierney RJ Suicide intervention training evaluation a preliminary report

Crisis 1994 1569-764 Kitchener BA Jorm AF Mental health first aid training for the public

evaluation of effects on knowledge attitudes and helping behavior BMCPsychiatry 2002 210

5 Linstone HA Turoff M The Delphi method techniques and applications2002 [httpisnjitedupubsdelphibook]

6 Snyder-Halpern R Thompson CB Schaffer J Comparison of mailed vsInternet applications of the Delphi technique in clinical informaticsresearch Proc AMIA Symp 2000 809-813

7 Kelly CM Jorm AF Kitchener BA Langlands RL Development of mentalhealth first aid guidelines for suicidal ideation and behaviour a Delphistudy BMC Psychiatry 2008 817

8 Kelly CM Jorm AF Kitchener BA Langlands RL Development of mentalhealth first aid guidelines for deliberate non-suicidal self-injury a Delphistudy BMC Psychiatry 2008 862

9 Kelly CM Jorm AF Kitchener BA Development of mental health first aidguidelines for panic attacks a Delphi study BMC Psychiatry 2009 949

10 Jorm AF Minas H Langlands RL Kelly ML First aid guidelines forpsychosis in Asian countries A Delphi consensus study Int J Ment HealthSyst 2008 22

11 Langlands RL Jorm AF Kelly CM Kitchener BA First aid for depression aDelphi consensus study with consumers carers and clinicians J AffectDisord 2008 105157-165

12 Hart LM Jorm AF Paxton SJ Kelly CM Kitchener BA First Aid for EatingDisorders Eating Disorders 2009 17357-384

13 Colucci E The cultural facet of suicidal behaviour Its importance andneglect AeJAMH 2006 53

14 Colucci E Cultural issues in suicide risk assessment Suicidal BehaviorAssessment of People-at-risk New Delhi SAGEKumar U Mandal MK 2009

15 Colucci E Martin G Ethnocultural aspects of suicide in young people asystematic literature review Part 1 Rates and methods of youth suicideSuicide Life Threat Behav 2007 37197-221

16 Colucci E Martin G Ethnocultural aspects of suicide in young people asystematic literature review Part 2 Risk factors precipitating agentsand attitudes toward suicide Suicide Life Threat Behav 2007 37222-237

17 Hawgood J DeLeo D Suicide Prevention Skills Training Manual AnAccredited Training Program Brisbane Australia Griffith University 2002

18 Mental Health and Drug and Alcohol Office Mental Health for EmergencyDepartments - A Reference Guide Sydney NSW Department of Health2002

19 Colucci E Recognizing spirituality in the assessment and prevention ofsuicidal behaviour WCPRR 2008 377-95 [httpwwwwcprrorgpdf03-022008027795pdf]

20 Hasson F Keeney S McKenna H Research guidelines for the Delphisurvey technique J Adv Nurs 2000 321008-1015

21 SurveyMonkey [httpwwwsurveymonkeycom]22 Hart LM Jorm AF Kanowski LG Kelly CM Langlands RL Mental health first

aid for Indigenous Australians using Delphi consensus studies todevelop guidelines for culturally appropriate responses to mental healthproblems BMC Psychiatry 2009 947

23 Minas H Colucci E Jorm AF Evaluation of Mental Health First Aidtraining with members of the Vietnamese community in MelbourneIJMHS 2009 319

24 Jorm AF Kitchener BA Mugford SK Experiences in applying skills learnedin a Mental Health First Aid training course a qualitative study ofparticipantsrsquo stories BMC Psychiatry 2005 543

25 Kitchener BA Jorm AF Mental health first aid training review ofevaluation studies Australian and New Zealand Journal of Psychiatry 2006406-8

doi1011861752-4458-4-4Cite this article as Colucci et al Mental Health First Aid guidelines forhelping a suicidal person a Delphi consensus study in IndiaInternational Journal of Mental Health Systems 2010 44

Colucci et al International Journal of Mental Health Systems 2010 44httpwwwijmhscomcontent414

Page 8 of 8